No More Smoke Screens

Last Wednesday, I had my six week follow-up appointment after the birth of my newest baby girl. The six weeks that had elapsed seemed like an eternity and yet instantaneous – like any spool of time surrounding a major life event does.

In the thick of summer vacation, I marched my older three girls into the office with me. Not ideal, but with the aid of electronic devices and some seats just outside the examination room door, I was able to avoid the embarrassment of an internal exam with the oldest two looking on and retching. I stationed my six year old’s chair full of crayons and coloring books at my head, the infant nestled in my chest.

Upon my arrival, the receptionist handed me the ubiquitous clipboard with the Edinburgh Postnatal Depression Scale. I knew it was coming. I was actually looking forward to it. I took it in hand almost giddily. There were a few reasons for this.

1. I didn’t need it.

Just a few days after the birth of my baby, a visiting nurse came to our house. Since it was a holiday weekend, we weren’t able to get an appointment with our pediatrician to check our breastfed baby’s weight and absence of jaundice so the hospital arranged for the home visit. While I expected the nurse to check the baby, she also looked after me, administering an EPDS. My score fell far below the range of danger for postpartum mood and anxiety disorders. Ever the overachiever, I joked with my husband that was a test I’d happily fail.

2.  But if I did, my answers to these questions would signal to my practitioners what sort of help I needed.

3.  If they gave the questionnaire to me, they gave it to all postpartum patients, which meant that all women had access to help if they were struggling.

epds

Jennifer Butler Basile

Still, when I handed the clipboard to the nurse in the examination room, and she followed up with questions like, ‘Have you ever thought of harming yourself or the baby?’, she asked them in a hushed voice. She apologized, saying she had to ask everyone.  Her tone insinuated it wasn’t me that was crazy, but it was her job to ask every mother in case one of them was. I knew part of her low volume was to spare my very aware six-year-old the world of suicide and psychosis, but I knew that wasn’t all of it. The apologies were born of shame, stigma; to separate me from those ‘tainted’ women, those we can’t speak of, for fear of ‘catching’ what they have.

But I was like them. I had what they had. I was just six years out.

Six years earlier, I would’ve been scared off by whispers like that. I wouldn’t have answered truthfully, if I’d thought it would smear me with that shame. Not because I didn’t need help. Not because I wasn’t having irrational thoughts. Not because I knew how to fix it myself. Because I felt that saying yes would be submitting to defeat.

I’m not trying to pin the shortcomings of postpartum care on this one nurse. If anything, this one nurse’s demeanor only shows just how difficult it is to discuss these matters. But the only reason I didn’t face these struggles this time is because someone asked the tough questions. Because a friend, a mother who had gone through the same struggles insisted I get help. And because once I healed, I knew how to prepare and preempt the struggles this time.

So wave the clipboard proudly. Answer the questions honestly. Ask for help loudly.

Mental health screenings should elucidate symptoms, not throw up smoke screens.

When does a perinatal mood disorder start?

Please read on to pinpoint when you or a woman close to you will begin to see signs of a perinatal mood and/or anxiety disorder.

  • When two lines appear on the pregnancy test
  • When pregnancy is unexpected
  • When pregnancy is finally achieved
  • When pregnancy is not achieved
  • When the mother loses the baby
  • When the mother chooses not to have the baby
  • When the adoption falls through
  • When the drastic changes in lifestyle that having a baby will induce begin to occur:
    • nausea
    • extreme exhaustion
    • no more wine with dinner or beer after a rough day
    • limited mobility
  • When the hormones at flux in the pregnant body affect thought processes
    • heightened anxiety at the amazing responsibility of growing and then caring for a baby
    • fear of the unknown or varied outcomes of gestation, labor, delivery, and aftercare
    • ambivalence over the new self the mother must create or become
    • mourning the loss of the former self
  • When medication regimens must be altered due to unknown effects of routine prescriptions on the fetus
  • When mother worries and feels guilty about continuing medication and its effects on fetus
  • When mother suffers a loss during pregnancy
    postpartum_pathways_logo

    postpartumpathways.com

    • death of a loved one
    • separation from partner
  • When the mother has no partner or support person
  • When a drastic transition occurs during pregnancy
    • moving homes and/or locations
    • away from support network
    • loss of own or partner’s employment
  • When labor and/or delivery does not go as planned or expected
  • Traumatic labor and/or delivery
    • physical trauma
    • emotional or psychological trauma
  • Complicated recovery from labor and/or delivery
    • infection
    • injury
  • When adoption is complete
  • Unexpected medical condition in infant
  • Loss of infant
  • Difficulty feeding infant
    • breastfeeding
    • colic
    • reflux
    • allergies
    • tongue tied
  • Extreme fatigue recovering from labor and caring for newborn around the clock
  • No routine
  • No schedule
  • No down time – constantly being needed, touched, suckled
  • Disappointment at real life not matching imagined version of motherhood
  • Hormones further thrown into flux after baby-growing part of process complete
  • Stress
  • Too much interference and advice from others
  • Not enough support and help from others
  • Isolation
  • Weaning child from breast (days, weeks, years after birth)
  • Being sole caregiver for a fragile, totally dependent being

After reading this list, it should be an incredibly simple and precise process to pinpoint exactly when you or a woman close to you will exhibit signs of a perinatal mood disorder. Diagnosing and treating it should be even simpler. And recovery? Piece of cake.


Hopefully it is quite obvious that the way I’ve chosen to frame this list is tongue in cheek. The individual items on the list are anything but. They are varied; some mutually exclusive and many overlapping – to show that there is no one road map for predicting, preventing, diagnosing, or treating perinatal mood disorders. Perinatal mood disorders come in many different forms with many different time lines. The one surefire tool to helping yourself or a woman close to you who is suffering is awareness. Awareness of the myriad possible causes and many symptoms that can present. And then reaching out.

To her. To your physician. Midwife. OB. GYN. Pediatrician. Counselor. Therapist. Psychologist. Psychiatrist. Friend. Mother. Partner. Neighbor.

With an illness this insidious, multi-faceted, and far-reaching, silence is not an option. The lives of our mothers, babies, and families depend upon it.

Advanced Screenings

 

They didn’t ask me to fill out the maternal mood questionnaire when I arrived for my annual physical today. I guess I’m no longer in the danger zone of postpartum. I no longer have a baby. My children are older. I’m more experienced. Everything should be easy-peasy at this point.

Or maybe they didn’t ask because my doctor knows. My chart already says ‘depressive disorder’. She just refilled my script for a low-dose of antidepressant. There’s no point in screening because we’re post-diagnosis.

She asked how I was feeling, how I was faring. A shrug of the shoulders. An approximation of one on my lips. Hunky-dory, doc. Some days are worse than others. I’m not cured, if that’s what you mean. I don’t want to run screaming from the house with my hair on fire – and haven’t for a while – but I still tend toward blah.

Maybe I’m expecting too much. I mentioned that I still have down days, but perhaps that’s the normal up and down of life. Yes, she said, you shouldn’t feel numb; you’ll have high points and low points. The lows seem so miserable, though. I know everyone has days when they don’t want to get off the couch, but my reasons seem so much more melancholy. A hollow near my heart, scooped out of the space where my joy once was. It’s not non-existent, but I haven’t noticed yet a day when the balloon inflates fully to fill that space.

I felt cheated somehow in not being ‘screened’. That it doesn’t matter since I’m beyond the threat of postpartum? That I’ve been given my happy pill so I should just shut up and take it? That I’ve been asked the same questions before and still don’t have any definitive answers?

But I suppose the screening isn’t perfect anyhow. A mother I know posted this status update after one of her trips to the doctor’s office.

At my physical I had to answer depression screening questions. One question was: “Do you feel like you’re failing your family or letting them down?” I laughed! Instead of circling the sometimes, often, or usually, I wrote in “Of course I do – I’m a working mother!”

No one questionnaire is going to get at the heart of each and every mother’s difficulties. I suppose it’s a step in the right direction that someone, anyone is asking – even if it’s a sheet of paper on a clipboard. But it should only be a beginning. Precisely because that question was laughable to that mom in its ironic understatement, we need to illustrate and represent all facets of a mother’s struggle – and give her the tools to do so – in order to help her when she needs it.

Image links to an online screening tool via Kent University (not specific to maternal mood disorders)

Click for an online screening tool via Kent State University (not specific to maternal mood disorders)

 

A Beast by Any Other Name

Is it better to know what ails me?

The malady and its moniker?

 

To know the reasons for things, for ways of being

 

To understand, anticipate, cope

 

Or does knowing give doom the upper hand?

Roll the boulder to the lip of the precipice?

 

Does it give power to what once may have been a bad mood, an off day, a stressful cycle?

 

Does it feed the beast –

and destroy the hope that there is an other side to this, an end and new beginning?

 

A beast that walks in the shadow of that boulder, goading me on . . .

The Perfect Storm

hurricane

When my husband and I learned of the imminent arrival of our third child, we were in shock.  Yes, we knew how things worked.  Yes, we’d always considered, even expected, a third child.  No, we were not ready for it right then.  After our second was born, we said we’d definitely want to wait until she was older than our first had been before we welcomed number three, which was just over two and a half.    The best laid plans . . .

Our second was eighteen months old when we found out I was pregnant.  In the weeks that followed, we walked around in a stupor.  As I went about my daily activities caring for the kids, I would find myself staring into space, lost in thoughts of third car seats, reconfiguring furniture in our already small house, finances, schedules.  The phone would ring – my husband calling from work – and we would stare into space together, our shock suspended in the telephone lines.  We knew we wanted this child and loved it already, but were totally caught off-guard by its timing.

It was also a difficult time in my extended family.  My uncle was battling a terminal brain tumor.  My announcement to my mother was made by way of my explanation for not visiting the ICU.  He died a few days later.  Four months later, my cousin was killed in a motorcycle accident.  My grandmother’s devastation was complete.  My mother’s own grief was wrapped up in worry for her mother.

Somehow, the days wound on, the months passing.  Caring for two children while carrying my third was starting to take its physical toll.  The usual aches and pains of pregnancy were amplified.  My left hip and pelvis were giving me more pain than ever.  As my due date approached, I felt extreme pressure, a heaviness, different than impending labor.  Having nothing to compare it to, I just assumed it was my body’s worn-out response to doing this a third time.

In the delivery room, my midwife asked me if there’d be a fourth if we had another girl.  “I hope not,” I’d said.  By the time I was pushing, I was sure there wouldn’t be.  Even after two natural births, I’d never experienced anything like it.  I actually uttered the words that infuriate me when I hear them in television portrayals of labor: “I can’t do this.”  But somehow I did.  And the nurses placed a perfect little girl in my arms.

I’d like to say all the shock and worry evaporated as soon as I saw her face.  She was gorgeous, I loved her, but I almost felt like a stranger observing the scene from afar.  I still hadn’t wrapped my head around the idea of starting over again with a third child.  And I wouldn’t get a chance to right away.  In the hours and days following her birth, a new challenge presented itself: getting out of bed.

When the nurse came to get me the next morning, she asked if it was the first time I’d been out of bed.  “No,” I answered, nonplussed, until I saw her face as she watched me move.  My walk was more of a shuffle, getting in and out of bed was slower than glacial melt.  Finally, after many such episodes throughout the day, she said, “Maybe we should send you for an x-ray to make sure you didn’t break anything.”  Break anything?  You’re not supposed to break anything when you have a baby – except your water.  Now she was making me nervous.

An x-ray confirmed her suspicions – and my pain.  I had a slight case of diastasis symphysis pubis.  Thank God it was slight because it meant the ligaments in my pubic bone had separated.  And as slight as it was, it was excruciating.

Once the adrenaline wore off and the soreness settled in, I couldn’t roll over in bed without crying.  It took me 45 minutes to get out of bed early one morning when I didn’t wake my husband or call the nurse.  My father brought me the old karate belt I’d left at their house to lash my legs together as I rotated them off the bed to come up to sitting.  Hip adduction was simply impossible.

My husband had taken two weeks’ vacation to help with the baby.  He didn’t know that, in addition, he’d be doing everything for the other kids, washing and folding clothes, preparing food, and helping me to and from the car like a little old lady.  The helplessness that can afflict a new mother was magnified ten-fold by my handicap.

I told my mother-in-law, “I’m finding it hard not to feel sorry for myself.”

She said, “I don’t blame you.”

Her answer surprised me.  Were things really that bad that I should be feeling sorry for myself?

Apparently so.  I worked my way into some sort of routine with a newborn who fed at no particular time, a preschooler who had to be in school at a precise time, and a toddler who took off her shoes and socks whenever she felt like it.  Weekly visits to a physical therapist worked me through a regimen that gave me a tenuous, yet workable, physicality.  And yet, four months after the baby’s birth, I still couldn’t cope.

I would reach my breaking point over hair elastics stretched to theirs over the top of a dining room chair.  God help the poor soul who dumped out the basket of toys I just filled.  My two oldest would jump when I started screaming at the top of my lungs out of seemingly nowhere over seemingly nothing.  I felt like a pot about to boil over and I was trying desperately to keep the lid on tight.  It was a particularly grueling drop-off at preschool one morning that crystallized everything.

Sleet was just turning to snow as we pulled into the parking lot.  I strapped the baby into the baby carrier on the front of me and moved around to the other side of the car.  My toddler had already taken off the hat and mittens I’d fought to get on her at the house.  I reached into the back seat where the preschooler was seated to depress the red button on her harness, instructing her to unclip the top part while I redressed the toddler’s extremities.

“I can’t, Mommy,” came the plaintive cry from the back seat as she stared out the window at the passing kids.  I instructed her to focus on what she was doing and try again.  This conversation repeated itself over and over like an audio loop, her despair and my frustration escalating each time.  Finally, I lunged into the car, swearing like a sailor, the baby bobbing in her carrier like a cork on the ocean, undoing the strap and telling her to get out of the car.

Then I stopped.  I scanned the parking lot around us for parents going to and from their cars.  Had anyone heard me?  Had they seen this terrible little episode?  Shouldn’t I have known I was getting out of control before it was too late?  Once my oldest was safely in the classroom and the rest of us safely home, I dissolved into tears recounting the story to my husband on the phone.

“I need help,” I said.

A few weeks later, I started a new kind of therapy.  I met weekly with a licensed social worker to discuss and treat what finally had a name: postpartum depression.

At the end of my first visit, I said to her, “So, do I have postpartum?”  In classic counselor speak, she replied, “Would you like me to say you have postpartum?”  I laughed and she joined me.  “I can go through the indicators if you’d like,” she said.  One by one, she ticked off every single one of my circumstances: unexpected pregnancy, death of a loved one(s), stress, difficult delivery, physical trauma, demands of caring for other children, anxiety.  “Does that make you feel better?” she asked.  Oddly enough, it did.  For the first time in months, I felt light leaving her office.  I wasn’t a failure and I wasn’t crazy.

This perfect storm was not forecast, but at least now I had some sort of outlook for the future.

Depression did not define me and the same is true for you. | Boundaries of the Soul

There comes a time when whatever is ailing you affects your quality of life so much that you go searching for answers.  For me, it was finding the Edinburgh Postnatal Depression Scale online.  Always one to minimize symptoms and having a surprisingly high threshold for pain (per my midwife) which perhaps translates to the emotional kind as well, I didn’t know how accurately I answered the questions.  But the fact that I sought it out was the first step in getting help.

Dr. Nicholas Jenner (see link below) wrote this incredibly helpful piece that I found too late to “diagnose” myself, but in reviewing his symptoms three and a half years into my own journey, I see how spot-on they are.  In fact, they made me smack my head in a “Gee, ya think?” sort of way.  Shit, is that what happened?

Maybe his article will reach you at a point somewhere before that one!

Depression did not define me and the same is true for you. | Boundaries of the Soul.

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