The Wild Winds of Fortune

The retrial of Andrea Yates for the murder of her children began this week. When I see pictures of her in the courtroom, the thought flashes across my mind, unbidden, that could have been me.

Postpartum depression is a condition which affects about 10-15% of new mothers, and which, thanks to women such as Brooke Shields, is finally getting some recognition in contexts outside criminal trials. Postpartum psychosis is a much more serious and uncommon condition, affecting one to two new mothers per one thousand births.

In 1990, in California, there were approximately 600 thousand babies born. Which means appromixately six hundred to a thousand new mothers would have developed PPP.

I was one of them.

The symptoms of PPP include hallucinations (had those — and it’s really interesting how they don’t seem at all like hallucinations at the time), delusional thoughts (does the thought that the baby is actively trying to harm me count?) and feelings (unrelieved guilt is not a rational emotion, even for a new mother), and suicidal or homicidal thoughts (check and, sadly, check). The scary thing is that women who have never been mentally ill can be affected, and that a woman with PPP can go from lucid to psychotic in a matter of hours. Few women with PPP actually kill either themselves or their baby, but the risk is still there, and in any case the psychosis is damaging enough even without loss of life.

I would not have ended up like Andrea Yates: I did not have five kids, and a history of schizophrenia. And I was lucky, I had a husband who listened and got me help when I said I was going to kill myself or the baby. Andrea Yates, on the other hand, had a husband who failed to properly oversee her with her children even though she had tried to kill herself twice following the birth of her fourth child, and had been in a psychiatric facility just a month before. And a doctor who, one week before the murders, reduced her psych meds.

It’s scary to admit to having been psychotic. While the social stigma against depression is easing, the social stigma against psychosis is not. The fact that the DSM-IV does not recognize postpartum psychosis as a separate category from other types of psychosis does not make it easier to talk about PPP. But speaking out is the first step to overcoming shame.

There are definite risk factors for PPP: a personal or family history of bipolar disorder, psychosis, schizophrenia, or PPP. (About that last one, I should note that while articles I’ve read indicate that women who suffered from PPP are at risk for it with subsequent pregnancies, it’s not a given: I had two more children without a reoccurence of the psychosis. I took the steps I outline below with subsequent pregnancies, and I firmly believe that’s the reason I didn’t become psychotic. However, it’s a definite risk factor.)

So what should women at risk and their partners do? (Note that these are my suggestions, based on common sense, and having walked the road myself, with some help from experts.)

Plan ahead:

Talk to your obstetrician specifically about any personal and family history of mental illness, and about what to look for and what to do if you develop problems. Don’t let it simply be an item that gets checked off when they take your medical history.

Plan to have as much help on hand after your baby is born. Investigate all sources of support — friends, neighbors, family, even in some cases employers. (Google wins my award for most family-friendly worker benefit: they allow new parents to expense up to $500 worth of take-out meals for four weeks after a new baby is born.) This is important for all new parents, really.

Find a lactation consultant. (Yes, I do believe in breastfeeding. Really.) Look for a consultant who has worked with women who have suffered from PPD or PPP. (My first LC had not, the ones I had with my second child had.) In any case, find a lactation consultant who will be supportive of whatever decisions you need to make, even if that means reducing or ending nursing. It is easier to talk to consultants when you are not awash in postpartum hormones.

After the birth:

As all the advice books tell all new mothers, sleep as much as possible. Rest when the baby naps. If you need several hours of uninterrupted sleep (say, four), make sure that you get it — either by pumping and storing breastmilk or using formula and supplementing if that’s what it takes. Have the father do as much as possible. This is true even as the baby gets older and you are physically more recovered from delivery: PPP can last for months.

Talk to people about what you are feeling. You will not be able to tell always when you are becoming depressed or even psychotic, and other people are more likely to pick up on it. Trust me, when they are happening, hallucinations seem absolutely real.

Don’t isolate. You need to sleep, but when you are awake and other people are around, interact with them.

Be prepared to go on psychiatric drugs if you need them. It is not a sign of weakness, or that you are a failure as a mother. If anything, it is a sign that you care enough about your child to be responsible and functional. Being psychotic will do far more damage to your relationship with your child than, say, having to give up breastfeeding in order to take anti-psychotics.

For partners of new mothers: listen to what she is saying. If she is exhibiting bizarre and irrational behavior, or seems to be disorganized or delusional, call her obstetrician right away. That’s what the experts say. I would go a bit farther: trust your intuition. Yes, new mothers are subject to mood swings, but only to some extent, and if she seems depressed and crying for days on end (or, conversely, irrationally elated, or swings rapidly between the two) she needs help. It’s not as serious as PPP, but PPD is really bad for everyone, too, so signs of significant depression need to be treated as well. Also, don’t dismiss as hyperbole statements that seem like mere overemotion: if your partner says, “the baby won’t stop crying,” when you know that the baby cries some but not all the time, don’t assume that she’s simply exaggerating. She could be hallucinating, and hearing the baby cry all the time, even when he’s not.* (I have that t-shirt.)

This is not meant to scare anyone: PPP is a relatively rare condition. But many of the steps above also apply to women at risk for/suffering from PPD, which affects 10-15% of new mothers. If they help just one or two women, it will be worth it.

Because it’s a black road to walk down, even if it does not end in the graveyard and the courtroom, as it did for Andrea Yates and her children.

*PPP is absolute hell for partners, as well as mothers; my husband could tell you that. Both of us wish we had known this information going into my first pregnancy (I have a family history of mental illness, so I was at risk) because we would have known what to do. As it was he did the best he could in dealing with a wife who was, it turned out, temporarily certifiably insane. Poor guy.

I was going to do everything “properly” with my first baby. Natural birth, no epidural, no C-section. And I was going to nurse my baby from the start; formula was evil. It’s amazing how dogmatic you can get when you really don’t know much about life.

From the start, things were not as I had so carefully planned them. I was sick all nine months of my pregnancy, including one hospitalization and several E.R. trips to remedy severe dehydration. Then the baby was late — very late — and we needed to induce labor.

Labor lasted thirty hours. It was hell. I kept up my resolution to not use drugs until the twenty-sixth hour when, physically exhausted and discouraged, I begged for an epidural. Several hours later, my son was born.

As many babies do, he needed to be fed frequently. I was still exhausted from labor, and being woken up every two hours to feed simply deepened that exhaustion. I vaguely remember begging my obstetrician not to send me home after 24 hours. He, of course, had no choice: insurance being what it was, I would have had to pay for the hospital bed an additional day (even if the hospital would have let me stay, which was unclear), money which I just didn’t have.

I went home to a household filled with grandparents just in time for the Thanksgiving holiday. Given that my mother-in-law was there, I was determined not to let her do all the work. (She had rearranged my living room furniture while I was in labor. I had something to prove, or thought I did.) And the baby still needed to be fed every two hours.

My husband called my sister and a local La Leche League consultant. No, it was important that we never supplement. I was ready to throw in the towel, but he held firm. (In his defense, he didn’t know anything more about this than I did.) My exhaustion deepened; I began to feel as though I was completely disconnected from the world.

I have suffered from depression a lot in my life, but nothing was like the pit I descended into then. It was as though the ground had dropped beneath my feet leaving me in utter blackness. I began to lose contact with my surroundings. My sleep deprivation was becoming severe. And the baby needed to be fed every two hours.

And he started to cry all the time. Nothing would soothe him. I would hold him, and he would be okay, but soon he would be crying again. I could not escape the crying. I started being unable to sleep between feedings, because the baby was crying all the time.

I still remember the day I went to the store to get a few items. I was on the way back when the baby started crying again. I felt such despair, the baby was crying again — would it never stop? Was there nothing I could do?

The baby was not in the car with me, but at home with my mother.

It says something about my mental state that it was not until several months later that I recognized the fact that I had been hallucinating. And probably not for the first time: about a year ago, my husband and I were talking about when my son was a newborn. “He cried all the time,” I said. My husband gave me a strange look,” No, he didn’t, no more than the other two. He didn’t get colicky until he was several months old.”

I was in freefall. Things came to a head a week later, when my husband had to go out of town for a business trip, leaving me and the baby alone in the house (my mother had gone back to Florida a day or so before). I looked at him calmly and said “If you leave, one or the other of us won’t be here when you get back.” What I did not tell him — or anyone — until years later was that I had already known I was going to kill myself. I thought there was a good chance I was going to kill the baby, too, and whatever spark of compassion I had in my soul (not fear of damnation — I was already damned) made me feel that this was grossly unfair to the baby. It wasn’t the baby’s fault I was its mother, he shouldn’t have to die for that.

He got angry, but called my obstetrician, who had me hospitalized. The first things the doctor did? Take the baby from my care, have my husband feed the baby formula, and have me sleep for twenty-four hours. When I woke up, I felt far more sane than I had in the previous two weeks.

There was still a lot to be done — my relationship with my son had been damaged by my psychosis, and that needed to be repaired. You may notice above that I refer to “the baby” and even “it”; that was how I thought of him. The social worker made me start calling him by name, and seeing him as my child rather than this alien being. When I think of those first days, I can’t help but think of him as being born during my second hospitalization — that was when I got to know him and see him as my child.

After that, we supplemented wherever it was necessary to make sure that I had at least four to six hours of uninterrupted sleep. And we did this with the second and third children as well. Prompt treatment of post-partum depression helped insure that I didn’t end up psychotic again.

So whenever I hear lactation fascists go on about how horrible bottles are, and how awful mothers are who feed their babies formula, I just want to tell them to go straight to hell. Hopefully, a hell as deep and black as the one I experienced when I came frighteningly close to committing suicide and murder.