The author and her son enjoy each other’s company after her recovery. (Photo reprinted with permission of The Commoneer.)
By Nicole Hostetter, contributor
Three weeks and two days after my son was born, I left a voicemail for my son’s pediatrician. I was desperate for advice about sleep following a string of nights without it.
“Why is he eating so much all night?” I asked, through tears. “I know they are supposed to eat every two-to-three hours but it just feels like so much. I can’t sleep. I don’t know what I’m doing wrong.”
I was blaming my lack of sleep on the baby. I thought maybe I was failing as a mother to provide him with enough milk. In reality, he was fine. He had gained a pound a week since birth and was topping the charts in all areas.
The real reason I couldn’t fall asleep was me. I was always anticipating the next wake up, and my anxiety would not subside.
The office called back and scheduled an appointment that afternoon with the pediatrician.
“Have you talked to your midwife about postpartum depression?” she asked me as I cried in her office, my tiny son gazing calmly into her face as she held him in her arms.
I felt my muscles tighten defensively and forced the tears to stop. I wouldn’t see my midwife for another three weeks and didn’t want to bother her with a call about sleep. I needed to present a facade of control and togetherness. What if they took my baby? What if they thought I was weak? Or worse — crazy?
Get it together, Nicole
“Oh, no. I don’t have that. I’ve been depressed before and I know what that feels like. This isn’t it.”
She looked up from the baby and held my gaze gently. My facade cracked. A fat tear rolled down my cheek.
“Are you trying to convince me, or yourself?” she asked matter-of-factly.
“Uh, well,” I stammered, caught off guard by the directness.
“Me?” I said, laughing through tears. “You? I don’t know. Both?”
She encouraged me to talk with my midwife, and get some more rest, adding that my son was healthy and perfect. And I left with the seed planted that I was in the grip of something beyond my control.
In denial
In an interview, Dr. Paula Max-Wright, a pediatrician at Bluestone Pediatrics in Harrisonburg, said pediatricians are actually best poised to spot maternal mental health problems because whereas new moms typically have only one checkup with their midwife or OB at around six weeks postpartum, a pediatrician sees mother and baby frequently in the first days and weeks after birth.
“Sometimes I’m the first person to say ‘Hey, you need to talk to somebody.’ And sometimes they insist nothing is wrong, and sometimes they say ‘Yeah, I’m having a really hard time,” Max-Wright said.
“And I’ve had some moms who are fine at first, and it happens much later in the first year too. It doesn’t always happen right after they are born.”
I had been one of the moms in denial.
But my pediatrician’s words stuck with me, and I left the appointment having to confront the possibility that my experience was not normal. What I had been brushing aside as the more common “baby blues” — a week or two of weepiness and occasional sadness as hormones readjust in the postpartum body — was in fact, something different, something that had begun to consume me.
A recent outpouring of candid stories from celebrities and regular moms alike surrounding the darker, more honest aspects of motherhood have prompted some national maternal health organizations to recognize the entirety of May as Maternal Mental Health Month.
It’s a time to reflect more deeply on the mental well-being of mothers and uniquely maternal illnesses, such as postpartum depression, which just last year affected more than 500,000 women nationwide and hundreds of new mothers here in the Shenandoah Valley.
Exact statistics on the prevalence of postpartum depression and other postpartum mood and anxiety disorders (PMADs) are difficult to obtain considering many women do not report the illness and seek no treatment. Conservative estimates place the rate at approximately one in 10 women, but other estimates are higher, at around 20 percent.
Last year Sentara Rockingham Memorial Hospital reported delivering nearly 1,800 babies, my son among them. If the 10-20 percent range is accurate, that translates from anywhere between 180-360 new mothers in our community just last year suffering from postpartum depression or another mood and anxiety disorder.
Even though dozens of other new moms around me were suffering too, in the depths of my illness I was convinced I was alone because I had never encountered anyone with postpartum depression before — even though the statistics make it likely I had without knowing it.
A new cadre of area maternal care providers is hoping to remove the stigma surrounding maternal mental health disorders and transform the way women are evaluated and treated during the vulnerable periods of pregnancy and postpartum, or after birth. These providers are seeking to educate and generate awareness among their peers and in the community as a whole, so that no mother feels afraid to come forward from her darkness to ask for help, and no mother feels she is alone.
‘You should be happy’
The “depression” part of postpartum depression is perhaps a misnomer. It’s part of the reason I think it took me so long to confront that there was a serious problem after my son was born last October.
I had heard about PPD during my prenatal appointments, but had not experienced it after my first child was born. Still, I was vigilant in watching for symptoms of classic depression because I had experienced mild depression and anxiety in other life stages. I watched carefully for signs of falling into the soft black hole where dullness and listlessness blanket every minute of the day. And although I felt some of that during the early postpartum days, other things were happening to me that didn’t fit into my understanding of what postpartum depression would be.
The endless crying and the feeling of despair and desperation were new to me. I didn’t experience them two years earlier after the birth of my daughter. And I also couldn’t understand the panic I felt every day, beginning the moment I woke up.
Sheer terror rolled over me in waves every day whether I looked at my baby or was apart from my baby. Cold sweats drenched my clothes each night.
I constantly felt sick to my stomach and had a complete loss of appetite, even though I should have been ravenous from breastfeeding. And underneath all of this my body felt like it was plugged into a low-voltage wall socket, constantly enveloped in an intense feeling that I was in danger and nothing would ever be okay again.
I went about trying to feign competency in the daily tasks of caring for my family, but as I rotely completed each chore I began judging myself harshly. Once one negative thought settled in my head, more followed suit. I believed them all to be true.
You should be happy.
You should be better at this.
You wanted a second child.
Why can’t you just be thankful for your healthy children?
If you continue to be this miserable, no one will love you anymore.
You will never feel better.
You will never have free time again.
Your life was so much better before.
Your family would probably be better off if you weren’t here being so miserable.
Sleep deprivation did not help. It amplified the maternal instinct to worry about my baby to the point of compulsion.
When the baby was awake, I worried when his next nap would be. When he was asleep I worried about what time he would wake up next. I worried about when I would get to sleep, so much so that I often found myself unable to because my heart was racing.
I worried I didn’t change his diaper often enough, or maybe I was changing him too much. I worried about him sleeping on his back. Then I worried about him sleeping on his stomach once we realized he slept better that way. I worried I wasn’t spending enough time with my daughter. Or husband. I worried about what to make for breakfast. I worried about leaving the house. I worried about people calling because I didn’t want to talk to anyone.
I was so engrossed in worrying and thinking that I usually didn’t even notice when my husband would enter whatever room I might be in. When I did notice I would jump, startled at his presence. I was on edge all the time.
The endless loop of worries, combined with the demands of caring for a newborn and toddler with their unique needs, led to severe exhaustion. My mind couldn’t keep up with itself. It had been rewired after my son’s birth to overdrive, going at full speed with no shut-off switch.
And I was terrified.
That there was a serious problem with my own mental health became unavoidable two days after the pediatrician visit, as we went to cut down our Christmas tree. On the drive to the farm, I hoped a car would T-bone my side of the vehicle and kill me. It felt like that was the only way out of the hole I had been tossed into.
I remembered the kids in the backseat and took the thought back.
I didn’t want harm to come to them. Just me. And I wouldn’t harm myself — I maintained enough control to respect that sacred uncrossable boundary to me.
It was cold comfort to know I still had a line of decency — that I wouldn’t be one of “those” mothers who made terrible headlines. A year before, I would have shaken my head and called “that kind of mother” a monster.
Now I understood that maybe some of those women had not been afflicted by desperation or insanity the way lightning strikes — suddenly, randomly — but instead perhaps they had been driven to their horrific deeds by a slow, burning, untreated illness that ate away at their sense of reason over time. Not lightning, but lava. The realization terrified me.
While we tree-shopped I tried to feign normalcy. For my husband. For my daughter. I wanted so badly to cut our tree and make a special memory that would wash away the desperation clinging to me every minute of the day.
My toddler ran ahead of us and the baby snuggled into my chest in his wrap. I wanted to be at home. I didn’t want the baby to wake up. I didn’t want to have to feed him in the cold. I didn’t want to have to deal with him.
I was anxious. Too alert. The crowd of merry families and the noise of the gas-powered tree cleaning machine was making me nervous.
After we found our tree and paid, my husband tied it to the car’s roof while I loaded the kids into their car seats. I exhaled deeply and sank into the passenger seat.
Pulling out of the parking lot my chest tightened and a wave of heat radiated from my heart. The pit of my stomach churned. It was the same feeling you might have if someone pointed a gun to your head. But there was no gun. There was hot chocolate and Christmas trees and children. I began to cry. The pediatrician was right. The truth was no longer deniable. I turned to my husband.
“Something is wrong with me.”
Causes and Effects
Tammie McDonald-Brouwer has been a midwife for the past 10 years and has seen her share of women suffering from postpartum mood disorders. She currently provides care at Shenandoah Women’s Health Center where she says she encounters struggling women on a regular basis.
“Sometimes we can see it kind of coming because of the symptoms they had during pregnancy,” McDonald-Brouwer said. “Sometimes we can say ‘We need to keep an eye on this lady because she may struggle because of the resources she has or doesn’t have, or the family situations or any number of other reasons.’ There’s definitely a group of women, because of social factors, who are more at risk because they don’t have the support.”
For other women, it wells up from a feeling of being overwhelmed, she said.
“They feel they can’t bond with their baby. They are not sleeping at all. Breastfeeding is a struggle. Or [traumatic] things that happened very earlier in their life are coming up and they can’t put it into words well yet,” she said. “It’s not a pinpoint straight thing but a lot of times it’s a combination of things.”
My symptoms were typical of what McDonald-Brouwer sees. Sleep deprivation was taking a toll on my mental well-being. The intense anxiety was causing difficulty bonding with my baby. The constant unshakable sadness and overwhelming feeling I was doing everything wrong.
“The ones that are early on within the first six weeks, they usually do manifest in more of the same way: very teary, struggling with bonding with the baby, struggling with breastfeeding, not getting sleep, and not having coping mechanisms about how to handle all of that. Her husband goes back to work and maybe you’ve been able to cope until now, and now it comes crashing down,” she said.
The author about a month before her son was born. (Photo reprinted with permission of The Commoneer.)
Many women who are medicated for preexisting mental health issues might stop their medication when they are trying to conceive. McDonald-Brouwer said there is a false belief that taking any form of a mood disorder medication during pregnancy is harmful, so primary care providers might stop a woman’s treatment during pregnancy.
This happened during my first pregnancy, when I was informed by the provider that I had potentially caused the baby harm by taking my low-dose antidepressant during the first few weeks after conception. I left the office following that appointment in tears and spent the next nine months convinced I had damaged my baby. Every time we would go in for a scan or a test I waited to see a hole in her heart or some other deformity in her perfect tiny body that I had caused. My mental health suffered, and although I didn’t end up with postpartum depression after my first was born, I didn’t get to enjoy my pregnancy the way I had hoped.
“Honestly, one of the risk factors is the media and what women hear from other providers,” McDonald-Brouwer said. “Taking women off their meds and saying you can’t be pregnant on this can be very harmful.”
So getting the message out to primary care providers is vital to treat maternal mental health issues.
“We have to start thinking that a mood disorder is a disease, and just because you want to get pregnant were going to stop treating your brain because you want to have a baby, and then were going to treat you again? That doesn’t make sense,” McDonald-Brouwer said.
The same can be said for women reluctant to start medication postpartum because they are breastfeeding.
New mothers with postpartum depression or another mood and anxiety disorder tend to struggle more with breastfeeding than healthy mothers. Working to foster that process and encourage breastfeeding, with its multiple benefits for mom and baby, even if the mother decides to pursue a course of medication, is something Max-Wright and McDonald-Brouwer both agree is important. The two are not mutually exclusive, they say.
“It’s better to take a medication while you’re nursing than to stop nursing,” Max-Wright said.
Most medications are carefully selected to minimize transference through breastfeeding, McDonald-Brouwer adds. “There is so little that goes into the breastmilk that it outweighs the risk.”
Almost all women get better if treatment is sought. If not, problems can linger for years.
“I think it just takes longer,” McDonald-Brouwer said. “And some will have struggles for the rest of their lives if they don’t find treatment.”
More Ways to Fight It
In March, the Food and Drug Administration approved the first treatment specifically for postpartum depression, called Zulresso. The drug has demonstrated in trials it can eliminate postpartum symptoms in most women after one 60-hour infusion, unlike the four-to-six weeks it takes for traditional antidepressants to reach peak effectiveness.
An example of the supplements and medication new moms take.
The treatment is not yet widely available, and is prohibitively expensive at this point, at around $30,000 per infusion. But just knowing it exists can provide validation for women like me, who can now say “Look, there is a treatment devoted solely to this illness. It is real.”
As for me and my treatment, once I acknowledged what was happening to me, with the help of my providers and their early detection, I was able to throw all I had at my illness, determined it would not defeat me.
I took the advice of my midwife and began taking an antidepressant. I also began taking supplements, herbs, probiotics, and vitamins — anything and everything that could possibly relieve my depleted fragile body and mind from the hell that had become my reality.
Between the supplements and prescriptions, I was taking about 15 pills each day, each one hopefully filling in a missing piece of the puzzle.
I prioritized rest. McDonald-Brouwer said this is often the missing link for women postpartum.
“We know it’s directly correlated to sleep,” she said. “If you can get one 4-hour stretch of uninterrupted sleep anywhere in your day, women cope better.”
Equally important to my treatment was meeting with a counselor each week. I needed a place to unload the emotional burden on someone other than my husband.
McDonald-Brouwer recommended counseling to her patients as an integral part of treatment for postpartum mood disorders but said she often encounters skepticism.
“I find that women are more resistant to counseling than medication,” she said. “I don’t know if it’s just talking to somebody that is difficult… It feels probably easier taking a pill. I think there is still a stigma about going to counseling.”
Vanquishing the Beast
I began counseling when my son was three weeks old, and it was a lifeline for me. No matter how bad things got on any given day, I knew if I could just make it to the next session, I would get one-on-one support.
Sitting on the couch I could open up about my insecurities and fears, my compulsions and anger. I was able to identify and change coping mechanisms that no longer served me and reexamine traumatic events I had only partially processed.
Early in my treatment, as I wept on her couch, afraid I would never recover and I was the only mother feeling this way, my counselor shared with me the motto of Postpartum Support International. In the darkness I clung to it, and in the light I share it with any other woman who is suffering alone right now from a maternal mental health disorder and the pain that comes with it:
“You are not alone.
You are not to blame.
And with help, you will be well.”
It was true. After nearly five months of this comprehensive care regimen, I awoke one day not to a panic attack, but to a quiet home and a peaceful mind. I was up even before the baby.
The coffee that morning tasted good.
I had an appetite for breakfast.
I greeted my son with laughter as he awoke, gazing and smiling at me as if I were the only person in the world.
He didn’t feel like a burden. He just felt like my son.
I kissed his warm head and buried my face in his soft fine hair, overwhelmingly thankful to finally feel like the mother I knew I could be.
I had another good day, then a string of them. And before I knew it, a week had passed and I had not had a panic attack. I felt in control. I felt happy. I felt normal, but even better than before in many ways — stronger, more confident, more content. Whole. I had beaten the beast.
More Support in the Valley
If early detection by one observant pediatrician helped me identify my illness and seek early treatment, imagine the impact on the entire local maternal community if more care providers were equipped to notice the signs of a postpartum mood disorder as early as possible.
That is the vision of McDonald-Brouwer, Max-Wright, and Tracy Koblish, who co-leads the monthly UPPS and DOWNS postpartum depression support group through Sentara RMH, and who recently took on the role as coordinator for the Shenandoah Valley Maternal Mental Health Coalition of which all three women are a part of.
The coalition is one of many Postpartum Support Virginia has launched across the state with the goal of providing universal education, screening, referral, and treatment for postpartum mood and anxiety disorders for all women of childbearing age.
“It’s a group of people, open to anybody, who is interested and has exposure to women postpartum or prenatally,” Koblish said. Area maternal-child healthcare professionals, mental health professionals and birth and postpartum support providers are all invited to coalition meetings to explore screening tools and receive training on how best to identify and provide support for women suffering from a postpartum mental health complication.
The goal is to get as many providers on board as possible so that every area woman has the opportunity to be screened for and treated for prenatal and postpartum mental health complications as soon as possible.
The coalition additionally hopes to increase education about postpartum mood and anxiety disorders and reduce the stigma surrounding mental health issues for mothers. Shame and guilt are often roadblocks for seeking treatment.
Koblish compared the discussion about maternal mood disorder treatment to the discussion around the opioid epidemic and the recent embrace of the overdose-reversal drug Narcan. As with many mental health issues, addiction included, what was once a taboo topic is now talked about openly especially in the wake of more media coverage and efforts of coalitions to help communities better understand addiction treatment.
Koblish said a concerted effort to put postpartum mood disorder screening protocols into the hands of as many providers as possible could be another tool. This way, she said, mothers in crisis can be identified and treated as quickly as possible.
“I’d like to see more screenings done and more talk about it in the news,” Koblish said. “As much publicity as possible will bring it to everyone’s awareness, and women will be more comfortable getting help and family members will be more aware too.”
Max-Wright agreed that early detection and treatment is important to ensuring a woman doesn’t suffer longer than necessary.
“There’s a lot of stuff you can see at two weeks that’s much easier to take care of than if you wait two more weeks,” she said. “Especially with mood and anxiety disorders. Right now you might just be not-so-great, but you could be about to go into a tailspin and if you can catch someone before that point wouldn’t it be nice to prevent that? Wouldn’t it be awesome to have a nice cadre of therapists and psychiatrists who are well versed in postpartum mood and anxiety disorders and who are able to treat them effectively?”
McDonald-Brouwer agreed.
“For some women, they stop breastfeeding, they feel like a failure, they may never have another child because they can’t handle that feeling again,” she said. “We’re getting much better about following and treating women, so if any woman feels like she has had this, or is still struggling and her baby is 2 years old, we say ‘Come in and let us take care of you.’ It is never too late to be treated.”
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