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.