Andrea Yates and me.

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.

PSA

My very favorite political and public affairs blog, Respectful of Otters, is back online after a nine-months absence. Rivka is scrupulously fair, willing to call out idiocy in any direction when she sees it, and she does her homework. She also writes well, which in the world of political blogging is nothing to sneeze at.

Check her out.

A letter to the Almighty.

Dear God,

I'm really furious.

I've been working on this acceptance business. Really, I have been. I have let go of needing to know why N. died even though she just turned forty. Of why C. has to raise two young daughters alone. I recognize that I cannot know how You are at work in this.

And I recognize that my trip to the emergency room -- asthma and a pulled pectoral muscle (i.e, chest pain and shortness of breath, a lot like cardiac symptoms) -- was a wake-up call that I need to be more careful about how I take care of my body. I can see a lesson here, and I am working at accepting that, too.

But the car? The three-year-old van going into complete and total transmission failure at midnight on I-5 in the Central Valley a hundred miles from nowhere, when we were so desperately rushing home so my husband could fly to be with his brother? What on Your green earth was that all about?

Does every step of this have to be a misery? Can't You cut me a little slack? I am working so hard.

My friend says that's not how You work. It's not? How do You work then? Are You some sort of detached God, who sits and grieves the human condition but does not one damn thing about it, for all Your vaunted omnipotence? Enquiring minds want to know here. Do You even exist? Is the sound of sheer silence You, or simply silence?

Forty. Dammit, God. She was forty.

Is it true then? Is life random and unfair? Is it pandemonium?

That smug young preacher at C.'s church last week in his sermon said that "blessed means happy-- not just happy but 'turbo-happy'." Oh, yeah? What does that make me? Or C.? Because I can assure You that we are not happy. He's grieving, and I'm mad. Because bad things have happened to us, is that evidence that You've turned your back on us? Screw that.

Your Son said "Blessed are they who mourn, for they shall be comforted." I'm taking that for a promise; C. needs comforting. (I notice that nowhere in the Beatitudes does it say "blessed are the seriously pissed off.")

I'm still here. I'm still mad.

Pat.

Requiem.

N. died today.

We were expecting it, of course. Still, getting a phone call telling you someone you love has died hurts, no matter how much it was expected. Even the San Diego Wild Animal Park -- an otherwise wonderful place -- can't help with that. I got the call when we wandering around near the lions and elephants, on our way to go see the bird show. I sat through the bird show and stared down the Eurasian Eagle Owl that flew right at me without so much as flinching.

I feel I should write something, but I am tired and discouraged, and, after a Long Island Iced Tea and a Hurricane downstairs at the bar here, inebriated. At the bar, they were playing a national trivia game. One of these games where you are hooked in via computer with players all over the country. N. and my brother-in-law would play this, sometimes, and they would call me to get help with some of the answers. I played my first several games of bar trivia tonight, as much to take my mind off of things as anything, but I think N. would have been amused. (Hey, N., I won three games at the bar! and on one of the games I ranked thirteenth nationally!)

Instead, until I can write something better, here is what I wrote about her last December.

Rest in peace, dear N.

For Whom the Bell Tolls.

I am two thousand miles from my home, in the dining room of my mother-in-law. I have come here to see my husband's sister-in-law, who is in the last stages of brain cancer.

I have never been around dying people before. My sister-in-law cannot talk, but so far she has been awake and responsive to people around her. She is surrounded by her family, my brother-in-law and nieces, and her parents and sisters. She is cared for by the people who love her most.

I was afraid of coming here. I was afraid she would be in pain. I was afraid for myself that I would find the sadness overwhelming, that being faced with the loss of this wonderful woman who has been my friend for seventeen years and who has brought such joy to my husband's family would cause me to cry all the time. She is too young, her leaving this earth too tragic.

Instead, even though it is unsettling, I also find being around her to be strangely comforting. She is dying -- so must we all. I will miss her, but I am no longer afraid for her. I am afraid for my brother-in-law, some, but only because we live in uncertain times and being a single parent is very hard for anyone.

It is true that how we think of people tends to be colored by who they were when we first met them. Part of me has always thought of C. as the boy who kept getting into scrapes his first year in college, as the mischievous and charming youngest child. Even after his children were born, part of me just sort of marvelled at the thought of him as a father (even though his wife as a mother seemed perfectly natural).

He is a man of integrity and great strength. He is allowing his wife to leave this earth with dignity and love. He is maintaining normality and calmness for his children, yet not pretending that everything is okay. Today he said to me, "People die. It's part of life. I want them [his kids] to understand that." There is not a touch of maudlinness in any of the people surrounding my sister-in-law, and he has been careful to see that that is the case.

When they were married, for various reasons, people questioned how they could end up together. They seemed to be very different people. But they loved each other very much, and now, I think it's apparent how right they have been for each other all along.

So, there is the waiting. Tomorrow is N.'s birthday, and there will be a small celebration. I bought a card and some chocolates. Buying the birthday card brought me to tears for the first time since I arrived: how do you buy a card for someone when all of the cards speak of a future that will never be?

I will leave on Sunday to fly home, having said goodbye. I am very glad that I am here.

Why I am not a lactivist.

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.

Sigh. You would think that people would have better things to do with their time.

I am referring to the flap over at Live Journal about the use of breastfeeding pictures as default icons. I was thinking it was an LJ thing, and once the initial flurry had passed, I could safely ignore it, until Patrick Neilsen Hayden at Making Light, one of the most interesting blogs around, posted "LJ's attack on women and mothers."

I am both. I have been a nursing mother, and I know some of the pitfalls and stresses caused by trying to nurse in public. I know how frustrating it is to have to deal with people who think that the sight of a baby being breastfed is WRONG! I know what it's like to have to pump milk in a bathroom stall because there was no appropriate place to do so.

And I say: If the fact that you cannot use a picture of your nursing baby as your default icon on your LJ creates a crisis for you, then you need to get a life.

People are still allowed to use pictures of themselves as icons other than default icons. People are still allowed to post pictures of themselves nursing their babies. (People use actually racy /pornographic images on some of their non-default icons.) No one is saying they can't.

Providers of services on the Internet are coming under increasing scrutiny. Listening to television news, you would think that MySpace (the site most singled out for attention by the fearmongers in the media and elsewhere) is nothing more than a den of pedophiles and pornographers waiting to seduce and corrupt the Youth of America. Live Journal operates in an area that is threatened with government regulation. They are walking a fine line between respecting the free speech of their users and running afoul of the more conservative elements out there who could make life difficult for them and by extension their users.

It has, however, been treated as a "LJ is against nursing mothers!" issue. It has also given some of the more radical -- and nasty -- pro-breastfeeding people an opportunity to make mothers who cannot breastfeed feel like shit. According to the nursing totalitarians, anyone who does not breastfeed their baby is an unfit mother, quite ignoring the fact that there are many caring, thoughtful mothers who cannot breastfeed. (If you notice in the article quoted, nursing is the only proper way to feed a baby, and women who don't are poor, or uneducated. Funny, all the women I know who've struggled with this have been bright, well-educated, and simply unable to nurse, and their babies have done fine.)[Edit: At the suggestion of commenters, the moderators redacted out the more inflammatory portions of the quoted article as being irrelevant to the discussion of LJ's policies.]

There are real issues facing nursing mothers. Having a place to either pump milk or nurse your baby while at work being a big one. Actually being prevented from nursing in public is another. Support for low-income mothers is another. Getting the information out about breastfeeding in a calm non-judgmental way is important.

Not being able to post a 100 pixel square picture of a woman nursing a baby as a default icon at LJ is not.


*For those lucky enough to not be familiar with what's going on, LJ asked a user to remove a breastfeeding woman icon as their default icon, and the user publicized this, and it became a "LJ is stifling free speech!" and "LJ is against nursing mothers!" sort of thing.