It’s temporary. That’s what I kept reading in books and hearing from my therapist. That’s what the gentle women who ran support groups for new mothers and who graciously took my frantic phone calls kept telling me. It’s temporary. You’ll get over it. Don’t worry, And by the way, you’re not going crazy.
They were right, of course. The illness was temporary and I’m fine now. I didn’t go crazy, but for a while I was certain that I was on my way. I went through the motions of living normally: getting dressed in the morning, chauffeuring my children around and feeding them three times a day, letting the muddy Airedale in and out whenever she barked. But inside, I wasn’t right.
Like an electrical system gone haywire, with lights blinking on and off sporadically or not going on at all or shining much too brightly, nothing in my brain seemed to operate predictably. Emotions and moods, thoughts and reactions were all inappropriate and exaggerated. I cried when I should have simply frowned, trembled when I should have slumbered, and numbed up when I should nave been high on love for my baby. A hundred years ago it would nave been called nervous prostration or puerperal illness. In the middle of this century, a nervous breakdown. And now, the official term for that awful first year of my baby’s life: postpartum depression.
Postpartum depression hit me when Max, my second child, was four months old, though it had been winding up to swing from the day he was born. It started with insomnia so bad that I’d lie awake for hours in bed between feedings, losing precious tidbits of the limited sleep allotted to all nursing mothers. Then came anxiety attacks, fear of being alone or with my kids, apathy for sweet little Max, and finally, terror that I would kill myself if I continued to lose my grip on life. There was a constant feeling of tension that no bath, no long walk, no glass of wine could cut through. I lost weight and gained mood swings. Some days I felt normal and was convinced I’d snapped out of it, but most days I felt tortured for all twenty-four hours. I would count the hours and minutes until my husband came home to take the kids from me, ending the long day of pretending to be a competent mother when I knew I was a potentially dangerous one. Then I would count the hours until I could go to bed, frantic with worry that I wouldn’t be able to sleep. Finally, I would count the minutes flipping forward on my circa-1973 clock radio until daylight told me I could quit trying to force sleep. When I was stuck in the quicksand that is postpartum depression (PPD) I didn’t believe the promises I read and heard about certain recoveries. I didn’t believe them because I had no proof that someone as bad off as I was had actually beaten it. I tried to uncover evidence that someone else who’d lived through similarly shaded days had survived. I embarked on this investigation with the fragments of energy I had left after taking care of two kids, two pets, and a house during the days that followed months of sleepless nights. Sleepless days, I called them, days that felt just like nights, with the same fogginess and hypersensitivity, the same sense of disorientation and loneliness one feels when gazing out the window at streetlights and moonshine in the middle of the night. I looked for survivors who could tell me how the story would end. When I finally realized that I needed professional help, I nagged my therapist to put me in touch with someone who’d reached the other side of the PPD tunnel. She never got back to me with a name, probably because most women who are through with PPD are through with it. They don’t want to be reminded of their darkest days by talking to someone in the midst of it, and they don’t want to waste their hard-earned mental health listening to the panic of a mentally ill stranger asking over and over again when the medicine will kick in and what does it mean that her fingers keep shaking? I couldn’t find any relief in a support group because I’d succumbed to PPD at the wrong time of year. I was at my sickest in July and August of my son’s first year, when the support group had recessed for the summer. By the time it started again in September, there were no veterans to learn from, only newcomers as needy or more so than I.
I looked to books for help. Someone, I thought, must have written about her experience with PPD. Somewhere between two glossy covers must be the words of assurance I craved; someone must be able to show me that she was as bound in misery as I was and still managed to untangle herself. But I couldn’t find such a book, because there were none on the shelves. All the books on PPD that I found were written by “experts,” social workers or psychiatrists or journalists who included all the facts on what PPD is and how it’s treated, along with tips on how to cope with laundry and child care until you’re better. Few, if any, had experienced PPD firsthand and if they had they didn’t write in detail about their travails. Instead, the authors offered anecdotes from faceless women. Lisa B, 34, thought she’d throw her baby out the window or Paula R, 27, had never experienced depression in her life. And while these snippets of information helped me learn that many of my discomforts had allegedly happened to someone else, they weren’t supportive enough. I wanted in on the whole story of a woman like me who was innocently conducting her job as a mother when she abruptly descended to hell. A real woman, with a face and a last name and a sink full of sticky cereal bowls. A woman who could give me proof–not composites and statistics–but proof that I wasn’t alone and that my pain would end.
I came close to finding that proof at a big bookstore with a cafe in the corner and hundreds of books on motherhood and mental illness. I’d decided to buy a paperback with a baby-girl pink cover that offered a clinical overview of PPD. I clutched it between my elbow and armpit while I pushed Max in his stroller to the front of the store. I plopped the book on the counter, where it was picked up by a clerk wearing jeans and gray curls. She admired the book before bagging it.
“I wish they had something like this when I had my son,” she said.
“Were you depressed after you had a baby?” I asked, shocked that someone her age had also gone through this anguish. Depression, it seems, is synonymous with pure self-absorption.
“Oh, yeah,” she said, still studying the book cover. “Really bad. But they didn’t have a name for it then. Nobody knew what was wrong. I just had to wait to get over it.”
“But you did?”
She smiled. “It gets better,” she said, her tone, her smile lines, her apparent ability to function in the world consoling me. I glanced at my son sleeping in the stroller beside me. I had loved him once, passionately, before all feeling had been snuffed out of me. Now I simply took care of him, gently but impersonally, like a salaried worker in an old-time orphanage. I wondered if I’d ever feel connected to him again.
“So, how’s your relationship with your son?” I asked the woman.
“Oh, we’re best friends now. He’s in college. We talk all the time.'”
The woman in the bookstore helped me more than the book I bought. Talking to her was the closest I came to some kind of solidarity with a fellow sufferer. I thought of her a lot over the next few months, as I got sicker and then well again. I thought of her on the phone to her boy, asking about midterm exams or when he’d be flying in for Thanksgiving. I thought of them sitting at the breakfast table together laughing over an old joke, the way close mothers and sons do. It seemed impossible during those days that I’d ever make it to where she was.
Postpartum psychiatric illness comes in three speeds. The postpartum blues, which affects up to 80 percent of women, consists of weepiness, irritability, and moodiness. It comes on days after delivery but usually resolves itself in two or three weeks. While not pleasant to go through–I had it for about a week after my first baby–it’s no more serious than a nasty spell of premenstrual syndrome. Postpartum psychosis (PPP), which, mercifully, affects only 1 in 1,000 of us, lies at the other end of the spectrum. It strikes suddenly within the first few weeks after delivery and brings with it horrifying symptoms such as delusions, hallucinations, and plans to kill oneself and the baby. Needless to say, it is extremely serious. If you’re experiencing any of the symptoms of PPP, please drop this book now and get yourself to an emergency room. Nothing you’re feeling is your fault. Once you get help, you and your baby will be safe and you will be well again soon.
Between the minor annoyance of the blues and the major assault of postpartum psychosis sits postpartum depression. An estimated 13 percent of all new mothers slide into this clinical depression, sometime in the year following delivery. That’s more than 400,000 women a year in the United States. It can start hours after delivery or when the baby is eleven months old. It causes insomnia, mood swings, anxiety, fear of losing control, weird thoughts of hurting the baby that you never intend to carry out but that scare the hell out of you nonetheless, thoughts of suicide, and a general feeling of being overwhelmed, disconnected from everyone you love, and desperately wanting to be mothered. All those tender and nurturing feelings you expected–or felt before the depression began–are absent most of the time. You can’t seem to locate your old self, though you’re aware enough to know she’s missing and to remember who she was.
Besides bringing on symptoms of depression, PPD can also manifest as an anxiety or obsessive-compulsive disorder. Or a combination platter of all three, as in my case. With postpartum anxiety, depression is replaced by a sense of doom. The physical symptoms of an anxiety attack–feeling as if you’re about to have a heart attack or faint or suffocate–are present for most of your waking hours. Postpartum obsessive-compulsive symptoms include repetitive, disturbing thoughts that can’t be reasoned away. All three versions of PPD can be treated with a combination of drugs (antidepressants, sleeping aids, and medicines to ward off anxiety) and psychotherapy.
Not everyone needs drugs to get better, but 25 percent of women will not recover without drugs, which could explain why so many women, especially of our mothers’ generation, lived self-medicated on Valium and martinis. Though PPD wasn’t diagnosed thirty years ago, it is often the first of many depressions a woman will suffer. A woman who has had PPD is much more likely to suffer depression again in her lifetime. The poet Anne Sexton, who spent years in and out of mental hospitals before killing herself at age forty-six, was first admitted to a mental hospital with postpartum depression. It seems probable that unresolved and undetected PPD lead to years of lingering depression and anxiety for many other women of her generation, too.
Seventy-five percent of women with PPD will get over it in a year without pharmaceutical help if they have the strength and patience to wait until their hormone levels return to normal. But as a friend of mine who suffered PPD said when she heard that statistic, “That’s a pretty long fucking year to wait.”
Postpartum depression isn’t new and it isn’t rare. When I told people I was writing this book, every female I mentioned it to had a strong reaction. My peers all knew someone who’d had the disease. “If you need to interview anyone, talk to my sister,” they’d say. Or “A friend of mine had that and it was terrible watching her go through it.” Women older than I tended to talk about themselves, always with nervous laughter. “Oh,” giggle, giggle, “my life story!” Or “Can you still have it fifteen years later?” Snort, chuckle. I even heard horror stories of PPD and PPP. A couple who came to dinner at our house told me about the wife of a famous artist who rocked in her darkened house with her baby in her arms for days while her husband was out of the country on business. When he finally grew frantic because she wasn’t answering the phone, he flew home and admitted her to a psychiatric hospital. One woman, whose children are now grown, told me her husband found her curled up in the fireplace before she was hospitalized for PPD.
Postpartum psychiatric illness has been around since Hippocrates mentioned it in 460 B.C., theorizing that it was caused by blood collecting “at the breasts of a woman” or postdelivery discharge going to the head instead of out of the body. His hypotheses reigned for about 2,000 years. In 1436, Margery Kempe, an illiterate mother of fourteen, dictated her life story. In the opening chapter of her book, she describes how she “became insane” and “despaired of my life and thought that I would not survive” after the birth of her first child. In 1838 a Frenchman named Jean Etienne Dominique Esquirol conducted the first scientific study of psychiatric illness and childbearing, proving the mental distress was indeed real. A year later, a researcher named M. J. MacCormack proposed using opium to treat what was then called puerperal mental illness. In 1847, J. MacDonald advocated the use of opium and Indian hemp instead of bleeding and restraint for postpartum patients. Finally, in 1858 Louis Victor Marce was the first to make the connection between PPD and the reproductive organs. The illness was taken seriously and treated as well as ancient technology allowed, until 1926, when two researchers declared that mental illness after childbirth was no different from other mental illness. They also successfully wiped the word postpartum from the psychiatry books. The late James A. Hamilton, who started studying postpartum psychiatric illness in the early 1960s and became one of the most respected researchers in the field worldwide, called this The Great Postpartum Suppression. He lamented that the years after its occurrence were “contaminated by the needless suffering of thousands, contaminated by the blood and tears of thousands of mothers and their babies.” Because of the suppression, progress in the field of PPD went the way of iceboxes and silent films until 1980. That was the year an international group of researchers formed the Marce Society to spread and share information on the illness, and to work on preventing and treating it. Even with the renewed interest in PPD, the American Psychiatric Association didn’t include the condition in its bible, the Diagnostic and Statistical Manual of Mental Disorders, until 1994.
It is misdiagnosed to this day. When I approached my primary care physician with an obvious set of PPD symptoms, he told me, in not so many words, that I was suffering housewife’s anxiety and I needed a good vacation. He probably would have added that I needed a good bang had he not been trying so hard to appear sensitive. I started seeing a different internist after I’d recovered. When I told him that the first doctor had missed the diagnosis of PPD even though it had been all but flashing in neon from my forehead, his response was, “Glad it wasn’t me. We all miss something sometime.” Another time this same second doctor, a renowned internist at one of Boston’s teaching hospitals, showed his obvious ignorance of PPD by suggesting that a lingering head cold, fever, and fatigue two years after my baby’s birth were part of the disease. “Maybe it’s that postpartum stuff,” he said, when he could find no basis for my physical symptoms. “Maybe you should see a therapist.”
Misdiagnosis isn’t something that can be measured with precision. But a recent random survey of PPD patients by the organization Postpartum Support International found that health professionals frequently don’t understand or correctly identify women’s symptoms as PPD. Even so-called authorities on the health of new mothers can get it wrong. A major magazine for parents recently ran a question-and-answer column and misled its readers by discounting PPD as a cause of a particular mother’s fear. In a letter allegedly from her husband, a man wrote that his wife feared daily that she would hurt their three-month-old baby and that she didn’t want to be alone with him. The magazine’s doctor responded that the woman probably had obsessive-compulsive disorder, which “should not be confused with postpartum depression.” In truth, such obsessions and fears of hurting a baby are strong symptoms of PPD and should be treated as such.
Doctors have no excuse for misdiagnosing the symptoms of PPD as “regular” depression or signs of a personality disorder. People with all types of depression exhibit similar symptoms such as sleeplessness, anxiety, and suicidal tendencies. But the syndrome of PPD–the exact combination, timing, and course of those symptoms–is distinct.
The professionals who study PPD currently blame the illness on a combination of physiological and psychological factors. In the past, the blame has swung to one side or the other, but now, “The definitive decision is it’s (caused by) everything,” says Jane Honikman, president of Postpartum Support International. Another top researcher, nurse-psychotherapist Jeanne Driscoll, sums up the indecision about the cause this way: “The state of the art is the state of confusion.”
On the physiological side, hormones are suspected as the cause of PPD. After delivery of the placenta, the hormones that have built to colossal levels during pregnancy drop drastically. Hormones are thought to control neurotransmitters in the brain, which are responsible for regulating mood and keeping one balanced. Therefore, the theory goes, out-of-whack hormones can lead to mental imbalance.
But there is no firm proof that hormones are the only culprits. Other research points to psychological triggers, such as a controlling personality; a history of miscarriage, stillbirth, or abortion; a traumatic or disappointing birth experience; a death in the family; poverty and other money problems; moving to a new home; a bad marriage; or a sick or colicky baby. Some experts blame PPD on the way our culture expects mothers to pick up where they left off the minute labor started. The illness is rarely found in cultures where there is a formalized period, usually forty days, of rest and support for new mothers. Still others say a history of depression– either in the woman herself or in her family–is the biggest precursor to PPD. But why such a history tips a woman toward PPD is just as unclear. Is it encoded in the brain chemicals and hormones? Or is it passed down through abuse, neglect, or simply bad role modeling from mentally ill parents?
Driscoll and her colleague, psychiatrist Deborah Sichel, believe that PPD brings to a head a lifetime of depression. They feel that most women with postpartum psychiatric illnesses have been depressed, obsessive, or anxious before, though many don’t even realize it. Once the hormonal changes of childbirth overwhelm the system, the depression erupts like water from frozen pipes.
I have no idea whether my history, my hormones, or my stresses are to blame for my case of PPD. If given a quiz, I could check off all of the above. Though I wasn’t able to admit it until I was nearly recovered, I have been mildly depressed for most of my life.
I also share with other PPD patients the common trait of depression running in the family. Both of my parents had been depressed, not to mention a grandfather and, I suspect, an aunt. The trajectory of my illness and the symptoms I experienced were pretty typical. Like many sufferers, I was a second-time mom with no history of PPD. I wasn’t depressed during my pregnancy, an event that tops the list of those factors that lead to PPD, but I had experienced many of the other common triggers. I’d had two miscarriages between my two healthy pregnancies and hadn’t resolved all my grief. My mother-in-law was dying of ovarian cancer, adding loads of stress to everyone in our family. I had no paid childcare or household help after Max arrived. And though my husband was tremendously supportive (studies show an unsupportive husband and bad marital relationship are common in PPD sufferers), help from my extended family was inconsistent. I was also facing a new stress: going back to work and sending Max to day care, a step I’d never taken with my first child. Any or all of these events could have made me succumb to PPD.
When I was diagnosed, I went into denial, thinking I could cure myself if I just tried harder or exercised or had a better attitude or faced my emotions or put off working or got some sleep. I was desperate to make the problem go away without resorting to drugs. Like many people, I believed antidepressants were for those too weak or lazy to solve their own problems. But the mistake I made was assuming I was in control of my brain. I thought that just because thinking and reasoning originates there I had the power to unclog the plumbing in the emotions and moods department. I was trying to fix my brain with my brain, which turns out to be as impossible as trying to fix your collapsed lung by taking a deep breath.
Finally, when some part of my brain accepted that I had neither scripted nor could erase what was happening to me, and when another part realized that my PPD was not a character flaw, but a physical illness that just happened to invade the tissue between my ears, I gave into the drugs. I started taking purple-and-peach-colored antidepressants that worked like shiny copper wiring to repair my head full of weak links. I felt sane again. I feel saner now than I ever have in my life. It was the nicest thing I’ve ever done for myself.
I got better, in fits and starts at first and then in a steady coast. I returned to my post as a good, loving mother. My son returned to my lap. My husband returned to work, though not without the scars of watching me deteriorate. Even as I write this, two years after my recovery, he can’t hold someone else’s baby. He says it reminds him too much of the months when I was sick and he was suddenly in charge of taking care of everyone by himself. My daughter, who didn’t react to my depression at all until it was over, got a normal family back. And I got me back. It turns out the old cliche about that which doesn’t kill you makes you stronger is true. I’m happier and more stable than I’ve ever been in my life. I accept now that there is no such thing as control. After a lifetime of figuratively clenching my fists in preparation for any approaching trouble, my body failed me anyway. My brain, the one organ I thought I had control of, fizzled the same way a heart or a liver can. And my recovery had nothing to do with my powers of control, either. The grace of pharmaceuticals and intelligent professionals can take credit for that. Now that I know that trouble can pop you in the jaw no matter how ready your fists are, I rarely bother clenching them at all. I’m not sure if this Zen-like world view is the result of living through a hellish experience or of the low dose of anti-depressants that continue to whitewash the angst that used to rule my life. I suspect it’s a combination of the two factors and I’m actually glad I collided with both of them.
I’ve accepted what happened to me: I lost my mind, for a little while. Temporarily.
Postpartum depression will be temporary for you, too, or your wife or sister or daughter or best friend. You may even be able to head it off by learning from me about its triggers and treatments. But know this: you are not alone. As long as this book is in your hands, consider my arm around your shoulder. I have been where you are and you, soon, will be where I am: back in the world, in love with your baby, sane and healthy and happy. I promise. It really is temporary. I’m proof.