Pregnancy is a whirlwind of tons of emotions and sensations – our body is ever changing as well as our wishes, dreams, plans, hopes, and expectations that come at us both from every direction. It’s completely normal to feel overwhelmed by the idea of bringing a new life and person into the world, while strangers and loved ones alike bombard you with their experiences and ideas.
Most pregnant women feel their appetite increase, an eager anticipation of the new life to come, and sleep should be good (excepting getting comfortable, which is always a challenge during pregnancy). Normal worries and concerns will be sprinkled throughout the pregnancy experience, but they shouldn’t dominate our days or nights.
Ask yourself, “Do I emotionally feel like ‘me’ most of the day?” “Can I to sleep at night?” “Am I mostly excited about the baby coming?,” and “Am I eating enough?”
All of the above should be answered with a resounding “YES.”
If you’re not, it’s time to seek out a specialized health care practitioner who can help understand what’s happening with you
Depression and anxiety affect just as many pregnant women as new mothers, and can happen to the strongest, most intelligent, and loving moms. If you experience depression during your pregnancy, speak to your obstetrician – this is called antepartum depression, and it affects a great many men and women during pregnancy. There are a number of ways you can get help, and not all of them involve medications.
Every trimester you should either be given a formal screening or simply asked a few key questions to determine how you’re doing emotionally. Receiving the right help during pregnancy will not only be best for you and your entire family, it will help you minimize the risk of postpartum depression.
Several days to weeks after giving birth, some mothers and fathers notice that they’re experiencing some strange symptoms, (most commonly) sadness, and/or anxiety after the birth of their child.
An estimated 1 out of every 6 women and 1 out of every 10 men experiences troubling depression or anxiety after the birth or adoption of a child, and in most people, these feelings are generally transient in nature. Given the tremendously stressful period of learning to live life with a newborn or new child is tremendously stressful to all involved, which is why we now recognize then men can also have postpartum mood disorders.
During the postpartum period, about 85% of women experience some type of mood disturbance. Generally, these symptoms are mild and short-lived; however, 10 to 15% of women and men go on to develop more significant symptoms of depression or anxiety. Postpartum psychiatric illnesses are typically divided into categories:
Postpartum Baby Blues
Postpartum Anxiety Disorders
It may be useful to conceptualize these disorders as existing along a continuum, where postpartum blues is the mildest and postpartum psychosis the most severe form of postpartum mood disorders.
Postpartum mood disorders are often characterized by despondency, emotional instability, anger, guilt, tearfulness, worrying, anxious thoughts or images, feelings of inadequacy and the inability to cope. It may occur shortly after the arrival of a new baby or many months later. For some, symptoms may begin in pregnancy; which is called or Antenatal Depression. The types of postpartum mood disorders generally lay on a spectrum.
Risk Factors for Developing Postpartum Mood Disorders:
Some things can make you more likely than others to develop postpartum mood disorders, including PPD. These are called risk factor. and having a risk factor or a few doesn’t mean for sure that you’ll have any problems with your mental health during or after pregnancy, but these risk factors, may increase your chances. Talk to your health care provider to see if you’re at risk for a postpartum mood disorder.
Your health care provider should assess you for PPD at your postpartum care checkups, including questions about your risks, feelings, stress level, as well as your moods.
Risk factors for postpartum mood disorders include:
Depression during pregnancy (Antenatal depression) or you’ve had major depression or another mental illness before
Family history of depression or mental health disorders.
You’ve been physically or sexually abused in your life
Problems with your partner, including domestic violence (also called intimate partner violence or IPV).
Extra stress in your life, such being separated from your partner, the death of a loved one, or an illness that affects you or a loved one.
Unemployed or have low income, little education, or little support from family or friends.
Pregnancy is unplanned or unwanted, or you’re younger than 19.
You have diabetes. Diabetes can be pre-existing diabetes (also called pre-gestational diabetes) or it can be gestational diabetes.
Pregnancy complications such as premature birth, birth before 37 weeks of pregnant
Multiples (twins, triplets) pregnancy
Pregnant with a child who has been diagnosed birth defects
You have trouble breastfeeding or caring for your baby.
Infant is sick or has ongoing health conditions.
Negative thoughts about being a mom and/or having trouble adjusting to being a parent.
Negative thoughts and feelings about being a mom may include:
Doubts that you can be a good mom
Pressure to be a perfect mom
Feeling that you’re no longer the person you were before you had your baby
Feeling that you’re less attractive after having your baby
Having no free time for yourself
Feeling tired and moody because you aren’t sleeping well or getting enough sleep
What is Antenatal Depression?
Depression during pregnancy, or antepartum depression, is a mood disorder just like clinical depression as far as symptoms are concerned. Mood disorders are biological illnesses that involve changes in brain chemistry and men and women who suffer from major depression are at a higher risk for developing antenatal depression.
During pregnancy, as I’m sure you’re aware, hormone changes affects the chemicals in your brain, including those that tell you to eat, sleep, and rest. Some of the other hormone changes are directly related to Antenatal Depression and Antenatal Anxiety. Unfortunately, these hormones can be exacerbated by difficult life situations, stress, and other factors which can result in depression during pregnancy.
Women with Antepartum Depression tend experience some of the following symptoms for at least two weeks:
Sleeping too little or too much
Loss of interest in activities that you usually enjoy
Recurring thoughts of death, suicide, or hopelessness
Anxiety without a trigger
Feelings of guilt or worthlessness
Change in eating habits
What Are The Postpartum Baby Blues?
Specialists believe that approximately 50 to 85% of women and men experience postpartum blues during the first few weeks after delivery; part of it is related to wildly changing hormone levels, the stress of having a new person to care for, and not feeling as though they’ll be able to manage. As this type of mood disorder is common – even expected, it can be more accurate to consider The Baby Blues as a normal experience following childbirth rather than a psychiatric illness.
Rather than feelings of sadness, men and women with The Baby Blues more commonly report mood lability, tearfulness, anxiety, and/or irritability. These symptoms typically peak on the fourth or fifth day after delivery and may last for a few hours or a few days, remitting spontaneously within two weeks of delivery.
While these symptoms are unpredictable and often unsettling, they do not interfere with a woman’s ability to function. No specific treatment is required; however, it should be noted that sometimes The Baby Blues heralds the development of a more significant mood disorder, particularly in women who have a history of depression.
If symptoms of depression persist for longer than two weeks, you should be evaluated to rule out a more serious postpartum mood disorder.
What Is Postpartum Depression (PPD)?
PPD tends to emerge over the first two to three months postpartum but can occur at any point after delivery. Some men and women actually note the onset of milder depressive symptoms during pregnancy. Postpartum depression is clinically indistinguishable from depression occurring at other times during a woman’s life.
In women and men who have milder cases of PPD, it can be quite difficult to detect postpartum depression because many of the symptoms used to diagnose depression (such as sleep and appetite disturbance, fatigue) also occur in postpartum women in the absence of depression.
The Edinburgh Postnatal Depression Scale is a 10-item questionnaire that may be used to identify women who have PPD.
On this scale, a score of 12 or greater or an affirmative answer on question 10 (presence of suicidal thoughts) raise concern and indicate a need for more thorough evaluation.
Edinburgh Postnatal Depression Scale (EPDS)
The questionnaire below is called the Edinburgh Postnatal Depression Scale (EDPS) The EDPS was developed to identify women who may have postpartum depression. Each answer is given a score of 0 to 3 . The maximum score is 30.
Please select the answer that comes closest to how you have felt in the past 7 days:
A score of more than 10 suggests minor or major depression may be present. Further evaluation is recommended.
Postpartum Depression (Postnatal Depression)
Postpartum depression is major depression that occurs after giving birth. Symptoms are present for most of the day and last for at least 2 weeks.
As many as 1 in every 7 women (14%) suffers postpartum depression .In a study of 209 women referred for major depression during or after pregnancy 11.5% reported start of depression during pregnancy, 66.5 % reported start of depression within 6 weeks after childbirth (early postpartum), and 22% reported onset 6 weeks after childbirth (late postpartum), One woman reported onset of depression at more than 27 weeks after childbirth.
Racing thoughts, psychotic symptoms (such as hallucinations or delusions), or a family history of bipolar disorder (BPD) may indicate bipolar disorder is present.
Treatment of depression during pregnancy and after childbirth is based on expert opinion. “Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide some direction”. The following are some treatment options that have been suggested .
Psychotherapy such as cognitive-behavioral therapy (CBT) OR interpersonal therapy
Mild Depression postpartum while breast-feeding
Psychotherapy with or without antidepressant (sertraline or paroxetine)
Psychotherapy AND fluoxetine
Alternative medications: sertraline or tricyclic antidepressant
Severe Depression postpartum while breast-feeding
Supportive services AND sertraline
Alternative medication: Paroxetine
Some of the symptoms of postpartum depression include:
Depressed or sad mood
Persistent sadness not otherwise explained
Loss of interest in usual activities
Feelings of guilt
Feelings of worthlessness or incompetence
Change in appetite
What Causes Postpartum Depression?
The postpartum period is characterized by a rapid shift in the hormonal environment. Within the first 48 hours after delivery, estrogen and progesterone concentrations fall dramatically. As these gonadal steroids modulate neurotransmitter systems involved in the regulation of mood, many investigators have proposed a role for these hormonal shirts in the emergence of postpartum affective illness.
While seems as if there is no consistent correlation between serum levels of estrogen, progesterone, cortisol, or thyroid hormones and the occurrence of postpartum mood disturbance, some investigators hypothesize that there is a subgroup of women who are particularly sensitive to the hormonal changes that take place after delivery. This population of women may be more vulnerable to PPD and to other hormonally driven mood disturbances, such as those occurring during the premenstrual phase of the menstrual cycle or during the perimenopause.
Other factors may play a role in the development of PPD. One of the most consistent findings is that among women and men who report marital dissatisfaction and/or inadequate social supports, postpartum depressive mental illnesses is more common. Several investigators have also demonstrated that stressful life events occurring either during pregnancy or near the time of delivery appear to increase the likelihood of postpartum depression.
While all of these factors may act together to cause PPD, the emergence of this disorder probably reflects an underlying vulnerability to affective illness. Women with histories of major depression or bipolar disorder are more vulnerable to PPD, and women who develop PPD will often go on to have recurrent episodes of depression unrelated to pregnancy or childbirth.
Who is at Risk for Postpartum Depression?
All women are vulnerable to postpartum depression, regardless of age, marital status, education level, or socioeconomic status. While it is impossible to predict who will develop PPD, certain risk factors for PPD have been identified, including:
Previous episode of PPD
Depression during pregnancy (antenatal depression)
History of depression or bipolar disorder
Recent stressful life events
Inadequate social supports
Marital or family issues
What Is Postpartum Anxiety?
Recent research suggests that 6% of pregnant women and 10% of postpartum women develop significant anxiety disorders. Sometimes these men and women experience anxiety alone, and sometimes they experience it in addition to postpartum depression. You do not have to be diagnosed with OCD to experience these common symptoms of perinatal anxiety
Generalized anxiety is common in both the general population and the postpartum period, however some women may also develop more challenging types of anxiety, such as panic disorder, and/or hypochondriasis in the postpartum period. Postpartum obsessive-compulsive disorder has also been reported, in which women report disturbing and intrusive thoughts of harming their infant.
The symptoms of anxiety during pregnancy or postpartum might include:
Feeling that something bad is going to happen
Disturbances of sleep and appetite
Inability to sit still
Physical symptoms like dizziness, hot flashes, and nausea
Risk factors for perinatal anxiety and/or panic disorder may include a personal or family history of anxiety, previous perinatal depression or anxiety, or thyroid imbalance; however, many men and women develop Postpartum Anxiety without any risk factors.
Postpartum Panic Disorder is a form of anxiety with which the sufferer feels very nervous and has recurring panic attacks after the birth or adoption of a baby or child. During a panic attack, he or she may experience any or all of the following:
Shortness of breath
Feeling of someone sitting on his or her chest
Numbness and tingling in the extremities.
Panic attacks seem to go in waves, but it is important to know that they will pass and will not hurt you.
What Is Postpartum Obsessive-Compulsive Disorder?
Postpartum Obsessive-Compulsive Disorder (OCD) is probably most misunderstood and misdiagnosed of the perinatal mood disorders. It is estimated that as many as 3-5% of new mothers and some new fathers will experience some of these symptoms. The repetitive, intrusive images and thoughts are very frightening and can feel like they come “out of the blue.” Fortunately, postpartum OCD is temporary and treatable with professional help. If you feel you may be suffering from one of this illness, know that it is not your fault and you are not to blame.
Research has shown that these images are anxious in nature, not delusional, and have very low risk of being acted upon. It is far more likely that the parent with this symptom takes steps to avoid triggers and avoid what they fear is potential harm to the baby.
Some women and men do not have OCD but are bothered by obsessive-compulsive symptoms.
Symptoms of Postpartum Obsessive-Compulsive symptoms can include:
Obsessions, also called intrusive thoughts, which are persistent, repetitive thoughts or mental images related to the baby. These thoughts are very upsetting and not something the woman has ever experienced before.
Compulsions, where the mom may do certain things over and over again to reduce her fears and obsessions. This may include things like needing to clean constantly, check things many times, count or reorder things.
A sense of horror about the obsessions
Overly occupied with keeping your baby safe
Compelled to do certain things over and over again to help relieve her anxiety and fears–This can include counting things, ordering things, listing things, checking and rechecking actions already performed, and cleaning repeatedly. This may manifest itself in cleaning, feeding, or taking care of the baby.
May recognize these obsessions but feels horror and shame associated with them
Obsessions or thoughts that are persistent, are repetitive and can include mental images of the baby that are disturbing
Fear of being alone with the baby
Women who suffer from PPOCD often know that these thoughts, actions, and feelings are not normal and do not act on them. But the obsession can get in the way of a mom taking care of her baby properly or being able to enjoy her baby. With the right treatment, women with PPOCD can experience freedom from being controlled by these obsessions and compulsions
Fear of being left alone with the infant
Hypervigilance in protecting the infant
Moms with postpartum OCD know that their thoughts are bizarre and are very unlikely to ever act on them.
Risk factors for postpartum OCD include a personal or family history of anxiety or OCD.
Given the potential adverse effects of untreated mood and anxiety symptoms in either the mother, father, careful screening and early recognition of anxiety symptoms during the postpartum period is recommended. Antepartum anxiety are temporary and treatable with professional help. If you feel you may be suffering from one of these illnesses, know that it is not your fault and you are not to blame.
What Is Postpartum Post-Traumatic Stress Disorder (PPTSD)?
Postpartum post-traumatic stress disorder (P-PTSD) often affects women who experienced a real or perceived trauma during childbirth or immediately after the baby was born.
P-PTSD is not a well-researched postpartum mood disorder, but for the estimated 3 to 16 percent of new moms and dads who suffer from it, this postpartum mood disorder is very real and incredibly frightening. P-PTSD can greatly impact the way they experience parenthood and care for their new baby.
For most women, the safe delivery of a healthy baby is moment remembered with great happiness. But not every new mom’s birth experience is a joyful one. In fact, more than a third of recently delivered moms describe their birth as traumatic, and the American College of Obstetricians and Gynecologists estimate that 3 to 16 percent display severe traumatic stress responses in the postpartum period. Like war veterans who suffer from PTSD – intrusive memories and flashbacks after suffering traumatic experiences on the battlefield – moms with P-PTSD look at their childbirth experience as a source of pain and anxiety and suffer from very similar post-traumatic symptoms.
P-PTSD is triggered by a traumatic event or events – real or perceived –– during pregnancy, labor, delivery, or during the postpartum period.
A mom-to-be may experience a traumatic event, such as severe morning sickness, fertility treatments, or serious pregnancy complications. Some women might experience trauma during childbirth if their labor was long and painful, if there was a cord prolapse, shoulder dystocia, a severe tear, previously undiscovered birth defects, hemorrhage, or an emergency C-section.
Trauma may result from a home birth that resulted in a transfer to a hospital due to complications; it could be from a planned hospital delivery that ended up unexpectedly at home. Trauma may develop if someone who’d wanted an intervention-free birth ends up requiring life-saving interventions.
Postpartum traumas may include having a premature baby, a baby who needs to be in the NICU, breastfeeding difficulties, or worse, a stillbirth or loss of a child early on.
Often the trauma is an emotional one: feelings of being powerless, of not being listened to, of not having adequate support during childbirth.
It’s important to remember that postpartum PTSD can develop after a real or perceived threat of death of the mother, father, or baby.
Traumas that may cause postpartum post-traumatic stress (P-PTSD) disorder include:
Unplanned or emergency C-section
Emergency complication such as prolapsed umbilical cord
Birth that requires invasive interventions such as vacuum extractor or forceps
Baby requiring a NICU stay
Lack of support and assurance during the delivery
Lack of communication from the birth and support team
Feelings of powerlessness
Symptoms of P-PTSD may include:
Nightmares and flashbacks to the birth or trauma
Anxiety and panic attacks
Feeling a detachment from reality and life
Irritability, sleeplessness, hyper-vigilance, startles more easily
Avoidance of anything that brings reminders of the event such as people, places, smells, noises, feelings
May begin re-experiencing past traumatic events, including the event that triggered the disorder
Women who are experiencing PPTSD need to talk with a health care provider about what they are feeling. With the correct treatment, these symptoms will lessen and eventually go away.
What Is Postpartum Psychosis?
Postpartum Psychosis (PP) is a severe, but treatable, form of mental illness that occurs after having a baby. It can happen ‘out of the blue’ to women without previous experience of mental illness. There are some groups of women, women with a history of bipolar disorder for example, who are at much higher risk. PP normally begins in the first few days to weeks after childbirth. It can get worse very quickly and should always be treated as a medical emergency. Most women need to be treated with medication and admitted to hospital.
Postpartum psychosis is the most severe form of postpartum mood disorders and is extremely – extremely dangerous. Postpartum Psychosis is a medical emergency. If you believe a friend or loved one is suffering from Postpartum Psychosis, don’t wait: call 911. This is an emergency.
Fortunately, postpartum psychosis It is a rare postpartum mood disorder that occurs in approximately 1 to 2 per 1000 women after childbirth.
The presentation is often dramatic, with onset of symptoms as early as the first 48 to 72 hours after delivery. The majority of women with puerperal psychosis develop symptoms within the first two postpartum weeks.
With the right treatment, women with PP do make a full recovery. Recovery takes time and the journey may be tough. The illness can be frightening and shocking for both the woman experiencing it and her family. Women do return to their normal selves, and are able to regain the mothering role they expected. There is no evidence that the baby’s long term development is affected by Postpartum Psychosis.
There are a large variety of symptoms that women with PP can experience. Women may be:
Excited, elated, or ‘high’.
Depressed, anxious, or confused.
Excessively irritable or changeable in mood.
Postpartum Psychosis includes one or more of the following:
Strange beliefs that could not be true (delusions).
Hearing, seeing, feeling or smelling things that are not there (hallucinations).
High mood with loss of touch with reality (mania).
Attempts to harm the child or herself
These are also common symptoms:
Being more talkative, sociable, on the phone an excessive amount.
Having a very busy mind or racing thoughts.
Feeling very energetic and like ‘super-mum’ or agitated and restless.
Having trouble sleeping, or not feeling the need to sleep.
Behaving in a way that is out of character or out of control.
Feeling paranoid or suspicious of people’s motives.
Feeling that things are connected in special ways or that stories on the TV or radio have special personal meaning.
Feeling that the baby is connected to God or the Devil in some way.
It appears that in most cases, postpartum psychosis represents an episode of bipolar illness; the symptoms of puerperal psychosis most closely resemble those of a rapidly evolving manic (or mixed) episode. The earliest signs are restlessness, irritability, and insomnia. Women with this disorder exhibit a rapidly shifting depressed or elated mood, disorientation or confusion, and erratic or disorganized behavior. Delusional beliefs are common and often center on the infant.
Auditory hallucinations that instruct the mother to harm herself or her infant may also occur.
Risk for infanticide, as well as suicide, is significant in this population.
How Are Postpartum Mood Disorders Treated?
Postpartum depression presents along a continuum, and the type of treatment selected is based on the severity and type of symptoms present. However, before initiating psychiatric treatment, any medical causes for mood disturbances (including thyroid dysfunction and/or anemia) must be excluded. Initial evaluation of a man or woman for postpartum mood disorders should always include a thorough and complete history, a physical examination, as well as routine laboratory tests.
Non-pharmacological therapies are often useful in the treatment of postpartum depression. It has been wildly demonstrated that short-term cognitive-behavioral therapy (CBT) was as effective as treatment with fluoxetine in women who have postpartum depression. Interpersonal therapy (IPT) has also been shown to be effective for the treatment of women with mild-to-moderate postpartum depression. Not only is IPT effective for treating the symptoms of depression, women who receive IPT may also benefit from significant improvements in the quality of their interpersonal relationships.
These non-pharmacological interventions may be particularly attractive to those patients who are reluctant to use psychotropic medications (such as women who are breastfeeding) or for women who have milder forms of depressive illness. Women with more severe postpartum depression may choose to receive pharmacological treatment, either in addition to or instead of these non-pharmacological therapies.
Only a few studies have systematically assessed the pharmacological treatment of postpartum depression.
Conventional antidepressant medications (fluoxetine, sertraline, fluvoxamine, and venlafaxine) have shown efficacy in the treatment of postpartum depression, standard antidepressant doses were both effective and well tolerated. The choice of an antidepressant should be guided by the woman’s prior response to antidepressant medication and side effect profile. Specific serotonin reuptake inhibitors (SSRIs) are ideal first-line agents, as they are anxiolytic, non-sedating, and well-tolerated.
For women who cannot tolerate SSRIs, bupropion (Wellbutrin) may be an alternative; although one pilot study suggests bupropion may not be as effective as SSRIs
Tricyclic antidepressants (TCAs) are frequently used and, because they tend to be more sedating, may be more appropriate for women who present with prominent sleep disturbance. Given the prevalence of anxiety symptoms, adjunctive use of a benzodiazepine (including clonazepam, lorazepam) may be very helpful to help ease anxiety and allow for relaxation.
While it’s difficult to reliably predict which women in the general population will experience postpartum mood disorders, it is possible to identify certain subgroups of women (such as men and women with a history of mood disorders) who are more vulnerable to postpartum affective illness.
Current research indicates that prophylactic interventions may be instituted near or at the time of delivery to decrease the risk of postpartum illness. Several studies demonstrate that women with histories of bipolar disorder or puerperal psychosis benefit from prophylactic treatment with lithium instituted either prior to delivery (at 36 weeks gestation) or no later than the first 48 hours postpartum.
Women and men with postpartum psychiatric illness are offered a variety of services by clinicians with particular expertise in these areas:
Clinical evaluation for postpartum mood and anxiety disorders
Consultation regarding breastfeeding and psychotropic medications
Puerperal psychosis is considered a psychiatric emergency that typically requires inpatient treatment.
Acute treatment with either typical or atypical anti-psychotic medications is indicated. Given the well-established relationship between puerperal psychosis and bipolar disorder, postpartum psychosis should be treated as an affective psychosis and a mood stabilizer is indicated.
Electroconvulsive therapy (ECT) is well-tolerated and rapidly effective for severe postpartum depression and psychosis.
Can I Take Medications While Breastfeeding?
The nutritional, immunologic and psychological benefits of breastfeeding have been well-documented. Women who plan to breastfeed must be informed that all psychotropic medications, including antidepressants, are secreted into the breast milk, though concentrations in the breast milk appear to vary widely throughout the day The amount of medication to which an infant is exposed depends on several factors including, dosage of medication, rate of maternal drug metabolism, and frequency and timing of feedings.
Over the past five years, we’ve learned more regarding the use of various antidepressants during breastfeeding. Available data on the tricyclic antidepressants, fluoxetine, paroxetine, and sertraline during breastfeeding have been encouraging and suggest that significant complications related to an infant’s exposure to these medications in breast milk appear to be rare. While less information is available on other antidepressants, there have been no reports of serious adverse events related to infant exposure to these medications.
Women who have bipolar disorder may discover breastfeeding may be much more problematic. The first concern is that on-demand, around-the-clock breastfeeding may significantly disrupt the mother’s sleep, which can increase her vulnerability to a relapse of bipolar disorder during the postpartum period. Second, there have been reports of toxicity in nursing infants who have been exposed to various mood stabilizers in the breast milk, including lithium and carbamazepine. Lithium, a gold standard in management of bipolar disorder, is excreted at high levels in the mother’s milk, so infant serum levels of Lithium are relatively high, which brings an increased risk of neonatal toxicity. Exposure to carbamazepine and valproic acid in the breast milk has also been associated with hepatotoxicity (liver toxicity) in a nursing infant.
If you’ve been diagnosed and treated for bipolar disorder, the very best thing that you can do for yourself and your infant is to develop a postpartum plan with your psychiatrist and your OB, based on the symptoms you experienced before you were pregnant. In this plan, you can address your postpartum concerns and ways to manage these concerns.
Additional Things You Can Do To Help Postpartum Mood Disorders:
With the controversy regarding the use of some antidepressants during pregnancy, many women are interested in other ways to help treat depression. As mentioned above, support groups, psychotherapy and light therapy are alternatives to using medication when treating mild to moderate depression.
In addition to these, you may want to talk with your health care providers about some of the other natural ways to help relieve the symptoms of depression.
If you do not feel comfortable talking with your health care provider about your feelings of depression, find someone else to talk with. It is important that someone knows what you are dealing with and can try to help you. Never try to face depression alone. Your baby needs you to seek help and get treatment.
Pay attention to the warning signs. Find out what triggers your mood disorder. Make a plan so that you know what to do if your symptoms get worse. Contact your doctor or therapist if you notice any changes. Ask friends or family to watch out for warning signs.
Stick to your treatment plan. Don’t skip psychotherapy sessions. Even if you’re feeling well, continue to take medication as prescribed.
Make some time to have fun. This can help remind you that everything won’t remain this stressful
Don’t isolate yourself, but don’t overcommit yourself, either.
Set realistic expectations. Be kind to yourself. Don’t pressure yourself to do everything. Ask for help when you need it.
New studies report acupuncture may be a viable option in treating depression in pregnant women.
Many foods have been linked to mood changes, the ability to handle stress and mental clarity. Diets high in caffeine, sugar, processed carbohydrates, artificial additives and low protein can all lead to issues regarding your mental and physical health. Make a conscious decision to start fueling your body with the foods that can help you feel better.
Learn about postpartum mood disorders. Empowerment leads us to feel better and more in control of our feelings.
Get exercise. Physical activity may help reduce symptoms
Exercise naturally increases serotonin levels and decreases cortisol levels.
Take a daily walk with your baby, or get together with other new moms for regular exercise.
Maintain an adequate diet. The Canada Food Guide is a useful reference in helping you choose how to eat well. Choose more protein and Omega 3, and fewer simple carbohydrates.
Avoid alcohol and illicit drugs. It may seem like they lessen your problems, but in the long run, they generally worsen symptoms and make the depression harder to treat.
Get adequate sleep. Lack of sleep greatly affects the body and mind’s ability to handle stress and day to day challenges. Work on establishing a routine sleep schedule that has you going to sleep and getting up at the same time. Ask for support from friends and family in watching the baby so you can get some sleep.
Available 24 hours a day, you will be asked to leave a confidential message and a trained and caring volunteer will return your call or text. They will listen, answer questions, offer encouragement and connect you with local resources as needed.
Office on Women’s Health: Provide national leadership and coordination to improve the health of women and girls through policy, education, and innovative programs.
March of Dimes: March of Dimes leads the fight for the health of all moms and babies. We believe that every baby deserves the best possible start. Unfortunately, not all babies get one. We are changing that.
Postpartum psychosis should be considered a medical emergency requiring immediate medical attention. Call 911 if you or someone you love is experiencing postpartum psychosis.
What is Postpartum Depression?
If you’ve just had a baby, you understand the mood swings that go along with your postpartum hormones. No matter how you love your child, how long you’ve wanted a baby, a new baby is stressful. Period. Lack of sleep, new important responsibilities, and a distinct lack of personal space and time to yourself, both parents can experience the baby blues. It’s extremely normal, but once symptoms of the baby blues last for a few weeks or worsen, you may be coping with postpartum depression.
Approximately 15% of new mothers and fathers will experience what is classified as postpartum depression (PPD). Symptoms may occur a few days after delivery or sometimes as late as a year later. People who experience postpartum depression will have alternating good days and bad days. Symptoms can be mild or severe, usually lasting for over 2 weeks.
There are lots of ways to help women suffering from postpartum depression, and remember that this is common, and you are never alone, no matter how you feel.
Is This Postpartum Depression or Is This The Baby Blues?
We know that you’ve just had a baby, and you’re expecting to be basking in the glory of a new life into this world. You thought you’d be celebrating with loved ones and enjoying every single second. But you’re not. In fact, you feel like crying or hiding away.
You thought you’d be joyous and excited, not weepy, exhausted, and anxiety-ridden. While you may not have intended this, you should know that mild depression, anxiety, and mood swings are totally normal. So normal that we can refer to them as the Baby Blues.
Approximately 50% to 75% of all new mothers will experience some negative feelings after giving birth. Normally these feelings occur suddenly four to five days after the birth of the baby.
Most women – to a greater or lesser extent – experience some symptoms of the baby blues after giving birth; the hormones that kept you pregnant are replaced by new hormones, lack of sleep, delivery, social isolation, major sleep loss, and stress, and it’s natural to notice them. Some women report that they feel emotionally fragile, sad, and overwhelmed. Generally the Baby Blues occur within a couple days of your delivery, last a week, and taper off by the second postpartum week.
What Are The Symptoms of Postpartum Depression?
In stark contrast from the baby blues, postpartum depression is a serious medical issue that should not be ignored. But how do you know the difference between postpartum depression and the Baby Blues?
PPD, as it’s often abbreviated, can look like the baby blues, so much so that they share many of the same symptoms, however the symptoms of postpartum depression last longer and are more severe. You may also feel hopeless and worthless, and lose interest in the baby. You may have thoughts of hurting yourself or the baby. Very rarely, new mothers develop something even more serious – postpartum psychosis – may have hallucinations or try to hurt themselves or the baby. They need to get treatment right away, often in the hospital.
The difference is that with postpartum depression, the symptoms are more severe (such as suicidal thoughts or an inability to care for your newborn) and longer lasting. Symptoms of postpartum depression begin either during pregnancy or within four weeks after having a baby.
The symptoms of postpartum mood disorders don’t differ from the non-postpartum mood disorders except that the feelings of guilt and inadequacy about being an incompetent mother feed a person’s worries about being less than an adequate parent.
You might find yourself withdrawing from your partner or being unable to bond well with your baby.
You might find your anxiety out of control, preventing you from sleeping—even when your baby is asleep—or eating appropriately.
You might find feelings of guilt or worthlessness overwhelming or begin to develop thoughts preoccupied with death or even wish you were not alive.
Feelings of profound sadness, emptiness, emotional numbness, irritability, or anger.
A tendency to withdraw from relationships with family, friends, or from activities that are usually pleasurable for the PPD sufferer
Constant fatigue or tiredness, difficulty sleeping, overeating, or loss of appetite
A strong sense of failure or inadequacy
Intense concern and anxiety about the baby or a lack of interest in the baby
Thoughts about suicide or fears of harming the baby
People with postpartum depression feel guilty about being depressed at a time when they are supposed to be happiest and may be reluctant to discuss their feelings.
People with postpartum depression often experience a loss of appetite, leading to extreme weight loss.
People with postpartum depression often report an increased yearning for sleep, sleeping heavily, but awakening (and unable to get back to sleep) the moment their baby makes a noise.
The distinguishing feature in postpartum depression is irritability. Episodes of irritability may be unprovoked or provoked by the slightest infraction. These episodes of irritability are often directed at the significant other or baby and may escalate to violent outbursts or uncontrollable sobbing.
People with severe postpartum depression often have terrible panic attacks, severe anxiety, and spontaneous crying, long after the duration of the “baby blues.”
These people with PPD may feel jealous of their infant and have difficulties bonding with their babies.
These are all red flags for postpartum depression.
The Edinburgh Postnatal Depression Scale is a screening tool designed to detect postpartum depression. Follow the instructions carefully. A score greater than 13 suggests the need for a more thorough assessment because you could have postpartum depression.
If you’re a new mother or father, please don’t hesitate to bring up these feelings with your doctor. Don’t let your doctor brush it off. If s/he does, find another doctor.
Signs And Symptoms of Postpartum Psychosis:
Postpartum psychosis is a rare, but extremely serious disorder that can develop after childbirth, characterized by loss of contact with reality. Because of the high risk for suicide or infanticide, hospitalization is usually required to keep the mother and the baby safe.
Postpartum psychosis (PPP) is the most severe form of postpartum depression, but fortunately it is the rarest form. It occurs in 1 to 2 out of every 1,000 pregnancies. The onset is very sudden and severe, normally within 2 to 3 weeks after giving birth. Postpartum psychosis develops suddenly, usually within the first two weeks after delivery, and sometimes within 48 hours.
Symptoms are characterized by a loss of touch with reality and can include:
Bizarre, erratic behavior
Thoughts of hurting the baby
Thoughts of hurting yourself
Rapid mood swings
Hallucinations (seeing things that aren’t real or hearing voices)
Delusions (paranoid and irrational beliefs)
Extreme agitation and anxiety
Suicidal thoughts or actions
Confusion and disorientation
Inability or refusal to eat or sleep
Thoughts of harming or killing your baby
Postpartum psychosis should be considered a medical emergency requiring immediate medical attention. Call 911 if you or someone you love is experiencing postpartum psychosis.
What Causes Postpartum Depression?
Just as in all types of depression, there is no single reason to point to as the definitive cause of postpartum depression. A variable combination of lifestyle, physical, and emotional factors can all play a part.
There’s no single reason why some new mothers develop postpartum depression and others don’t, but a number of interrelated causes and risk factors are believed to contribute to the problem.
Hormonal changes. After childbirth, women experience a big drop in estrogen and progesterone hormone levels. Thyroid levels can also drop, which leads to fatigue and depression. These rapid hormonal changes—along with the changes in blood pressure, immune system functioning, and metabolism that new mothers experience—may trigger postpartum depression.
Physical changes. Giving birth brings numerous physical and emotional changes. You may be dealing with physical pain from the delivery or the difficulty of losing the baby weight, leaving you insecure about your physical and sexual attractiveness.
Stress. The stress of caring for a newborn can also take a toll. New mothers are often sleep deprived. In addition, you may feel overwhelmed and anxious about your ability to properly care for your baby. These adjustments can be particularly difficult if you’re a first-time mother who must get used to an entirely new identity.
Risk Factors For Postpartum Depression:
Several factors can predispose you to postpartum depression:
The most significant is a history of postpartum depression, as a prior episode can increase your chances of a repeat episode to 30-50%.
Mood Disorders: A history of non-pregnancy related depression or a family history of mood disturbances is also a risk factor.
Addiction: People with any history of depression, anxiety, alcohol or another substance use disorder prior to the pregnancy are at risk for developing depression during the pregnancy or within a few weeks after delivery.
Prenatal depression – Depression during pregnancy may be the strongest predictor for later suffering from PPD.
History of previous depression – Although not as strong a predictor as a depressive episode during the pregnancy, it appears that women with histories of depression previous to conception are also at a higher risk of PPD than those without
Examples of specific illnesses that have been associated with being associated with the potential to develop postpartum depression include any form of major depression, such as premenstrual dysphoric disorder, bipolar disorder, and generalized anxiety disorder.
Maternity blues – Especially when severe, the blues may herald the onset of PPD.
Recent stressful life events
Inadequate social supports
Poor marital relationship – One of the most consistent findings is that among women who report marital dissatisfaction and/or inadequate social supports, postpartum depressive illness is more common.
Childcare stress – Difficult infant temperament
In addition, three factors are less definitively predictive, but still arise consistently as factors that increase a woman’s risk of PPD, especially in combination with one or more of the factors listed above:
Single marital status
Unplanned or unwanted pregnancy
Lower socioeconomic status
What Is The Treatment For Postpartum Depression?
Postpartum depression (PPD) sometimes goes away on its own within three months of giving birth. But if it interferes with your normal functioning at any time, or if “the blues” lasts longer than two weeks, you should seek treatment. About 90% of women who have postpartum depression can be treated successfully with medication or a combination of medication and psychotherapy. Participation in a support group may also be helpful. In cases of severe postpartum depression or postpartum psychosis, hospitalization may be necessary. Sometimes, if symptoms are especially severe, electroconvulsive (ECT) therapy may be used to treat severe depressions with hallucinations (false perceptions) or delusions (false beliefs) or overwhelming suicidal thoughts
Untreated postpartum depression can affect your ability to parent. You may:
Not have enough energy
Have trouble focusing on the baby’s needs and your own needs
Not be able to care for your baby
Have a higher risk of attempting suicide
Feeling like a bad mother can make depression worse. It is important to reach out for help if you feel depressed.
Researchers believe postpartum depression in a mother can affect her child throughout childhood, causing:
Delays in language development and problems learning
Problems with mother-child bonding
More crying or agitation
Shorter height and higher risk of obesity in pre-schoolers
Problems dealing with stress and adjusting to school and other social situations
Postpartum depression, like other mental illnesses, presents along a continuum, and the type of treatment selected is based on the severity of the depression and type of symptoms present. However, before beginning psychiatric treatment, medical causes for mood disturbance (such as, thyroid dysfunction, anemia) must be excluded. Initial evaluation should include a thorough history, physical examination, and routine laboratory tests.
Non-pharmacological therapies are useful in the treatment of postpartum depression, including CBT, ITP, and couples counseling.
In a randomized study, it was shown that short-term cognitive-behavioral therapy (CBT) was as effective as treatment with fluoxetine (Prozac) in women with postpartum depression.
Interpersonal therapy (IPT) has also been shown to be effective for the treatment of women with mild to moderate postpartum depression. Not only is IPT effective for treating the symptoms of depression, women who receive IPT also benefit from significant improvements in the quality of their interpersonal relationships
These non-pharmacological interventions may be particularly attractive to those reluctant to use psychotropic medications (such as women who are breast-feeding) or for people with milder forms of depressive illness. Women with more severe postpartum depression may choose to receive pharmacological treatment, either in addition to or instead of, these non-pharmacological therapies.
Only a few studies have systematically assessed the pharmacological treatment of postpartum depression. Conventional antidepressant medications have shown efficacy in the treatment of postpartum depression at standard antidepressant doses were effective and well tolerated.
The choice of an antidepressant should be guided by the person’s prior response to antidepressant medication and a given medication’s side effects.
Specific serotonin reuptake inhibitors (SSRIs) are ideal first-line agents, as they are anxiolytic, non-sedating, and well tolerated (examples include: fluoxetine, sertraline, fluvoxamine, and venlafaxine)
For women who cannot tolerate SSRIs, bupropion (Wellbutrin) may be an alternative; although one pilot study suggests bupropion may not be as effective as SSRIs.
Tricyclic antidepressants (TCAs) are frequently used and, because they tend to be more sedating, may be more appropriate for women who present with prominent sleep disturbance.
Given the prevalence of anxiety symptoms in this population, adjunctive use of a benzodiazepine (e.g., clonazepam, lorazepam) may be very helpful.
Can I Breastfeed My Child If I’m On Medication?
The nutritional, immunologic, and psychological benefits of breastfeeding have been well documented. Women who plan to breastfeed must be informed that all psychotropic medications, including antidepressants, are secreted into the breast milk. Concentrations in the breast milk appear to vary widely. The amount of medication to which an infant is exposed depends on several factors, including dosage of medication, rate of maternal drug metabolism, and frequency and timing of feedings (Llewelyn and Stowe).
Over the past five years, data have accumulated regarding the use of various antidepressants during breastfeeding (reviewed in Newport et al 2002). Available data on the tricyclic antidepressants, fluoxetine, paroxetine, and sertraline during breastfeeding have been encouraging and suggest that significant complications related to neonatal exposure to psychotropic drugs in breast milk appear to be rare. While less information is available on other antidepressants, there have been no reports of serious adverse events related to exposure to these medications.
For women with bipolar disorder, breastfeeding may be more problematic.
First is the concern that on-demand breastfeeding may significantly disrupt the mother’s sleep and thus may increase her vulnerability to relapse during the acute postpartum period. Second, there have been reports of toxicity in nursing infants related to exposure to various mood stabilizers, including lithium and carbamazepine, in breast milk. Lithium is excreted at high levels in the mother’s milk, and infant serum levels are relatively high, about one-third to one-half of the mother’s serum levels, increasing the risk of neonatal toxicity. Exposure to carbamazepine and valproic acid in the breast milk has been associated with liver damage in the nursing infant.
Can We Prevent PPD?
While it is difficult to reliably predict which women in the general population will experience postpartum mood disturbance, it is possible to identify certain subgroups of women (i.e., women with a history of mood disorder) who are more vulnerable to postpartum affective illness. Current research indicates that prophylactic interventions may be instituted near or at the time of delivery to decrease the risk of postpartum illness.
Several studies demonstrate that women with histories of bipolar disorder or puerperal psychosis benefit from prophylactic treatment with lithium either prior to delivery (at 36 weeks gestation) or no later than the first 48 hours postpartum.
For women with histories of postpartum depression, several studies have described a beneficial effect of prophylactic antidepressant (either TCAs or SSRIs) administered after delivery. Patients with postpartum psychiatric illness are offered a variety of services by clinicians with particular expertise in this area:
Clinical evaluation for postpartum mood and anxiety disorders
Consultation regarding breastfeeding and psychotropic medications
The most important task of infancy is the bonding process between the infant and parents, as the success of this wordless relationship enables a child to feel secure enough to develop fully, and affects how the child will interact, communicate, and form relationships throughout life.
A secure attachment between parent and child is formed when the parent responds warmly and consistently to your baby’s physical and emotional needs. When your baby cries, you quickly soothe him or her. If your baby laughs or smiles, you respond in kind. You and your child are in synch. You recognize and respond to each other’s emotional signals.
Postpartum depression can interrupt this bonding. Depressed parents may be loving and attentive sometimes, but others may react negatively or not respond at all. Sadly, parents with postpartum depression tend to interact less with their babies, and are less likely to breastfeed, play with, and read to their children. They may also be inconsistent caregivers.
However, learning to bond with your baby not only benefits your child, it also benefits you by releasing endorphins that make you feel happier and more confident as a parent.
Make yourself and your baby the priority. Give yourself permission to concentrate on yourself and your baby – there is more work involved in this 24/7 job then in a full-time job.
Try to remember that we, as human beings are naturally social. Positive, happy, and supportive social contact relieves stress faster and more efficiently than any other means of stress reduction. Historically and from an evolutionary perspective, new parents received help from those around them when caring for themselves and their infants after childbirth. In today’s world, new mothers often find themselves alone, exhausted, and lonely for supportive adult contact.
When you’re feeling depressed and vulnerable, it’s more important than ever to stay connected to family and friend – even if you’d rather be left alone. Isolating yourself will only make your situation feel even bleaker, so make your adult relationships a priority. Let your loved ones know what you need and how you’d like to be supported.
In addition to the practical help your friends and family can provide, they can also serve as a much-needed emotional outlet. Share what you’re experiencing – all of it – with at least one other person, preferably face to face. It doesn’t matter who you talk to, so long as that person is willing to listen without judgment and offer reassurance and support.
Even if you have supportive loved ones, you may want to consider seeking out other women who are dealing with the same transition into motherhood. It’s very reassuring to hear that other mothers share your worries, insecurities, and feelings. Good places to meet new moms include support groups for new parents or organizations such as Mommy and Me. Ask your pediatrician for other resources in your neighborhood.
One of the best things you can do to relieve or avoid postpartum depression is to take care of yourself. The more you care for your mental and physical well-being, the better you’ll feel. Simple lifestyle changes can go a long way towards helping you feel like yourself again.
Studies show that exercise, for some people, may be just as effective as medication. But don’t to overdo it: a 30-minute walk each day can work wonders. Stretching exercises such as those found in yoga have shown to be especially effective. Make certain that you’re cleared by your OB/GYN before you begin to exercise.
A full eight hours may seem like an unattainable luxury when you’re dealing with a newborn, but poor sleep makes postpartum depression worse. Do what you can to get plenty of rest – enlist the help of your partner or family members to catching naps when you can.
Make some time to relax and take a break from your parental duties. Find small ways to pamper yourself, like taking a bubble bath, savoring a hot cup of tea, or lighting scented candles. Get a massage. Splurge on a pedicure.
When you’re depressed, nutrition often suffers, because you may not have any appetite. As you know, what you eat has an impact on mood, as well as the quality of your breast milk, so do your best to eat well.
Sunlight lifts your mood – and prevents vitamin D deficiency – so try to get at least 10 to 15 minutes of sun per day.
More than half of all divorces take place after the birth of a child. For many people, the relationship with their partner is their primary source of emotional expression and social connection. The demands and needs of a new baby can get in the way and fracture this relationship unless couples put some time, energy, and thought into preserving their bond.
The stress of sleepless nights and responsibilities can leave you feeling overwhelmed and exhausted. And since you can’t take it out on the baby, it’s all too easy to turn your frustrations on your partner. Instead of finger pointing, remember that you’re in this together. If you tackle parenting challenges as a team, you’ll become an even stronger unit.
Many things change following the birth of a baby, including roles and expectations. For many couples, a key source of strain is the post-baby division of household and childcare responsibilities. It’s important to talk about these issues, rather than letting them fester. Don’t assume your partner knows how you feel or what you need.
It’s essential to make time for just the two of you when you can reconnect. But don’t put pressure on yourself to be romantic or adventurous (unless you’re both up for it). You don’t need to go out on a fancy date to enjoy each other’s company. Even spending 15 or 20 minutes together—undistracted and focused on each other— can make a big difference in your feelings of closeness and togetherness.
Help! My Loved One Has Postpartum Depression!
If your loved one is experiencing postpartum depression, the best thing you can do is to offer support. Give her a break from her childcare duties, provide a listening ear, and be patient, and understanding.
If your partner has PPD, remember that you also need to take care of yourself. Dealing with the needs of a new baby is hard for all involved. If your significant other is depressed, you are dealing with two major stressors.
Don’t wait, just offer help around the house. Chip in with the housework and childcare responsibilities. The person may not feel it is appropriate to ask for any help from anyone.
Encourage talking about feelings, which can be awkward, but is necessary for your loved one. Listen to your loved one without judging or offering solutions. Instead of trying to fix things, simply be there for your loved one to lean on.
Make sure your loved one takes time for themselves. Rest and relaxation are important. Encourage the parent to take breaks, hire a babysitter, or schedule some date nights.
Go for a walk together. Getting exercise can make a big dent in depression, but it’s hard to get motivated when you’re feeling low.
Additional Resources For Postpartum Depression:
Postpartum Health Alliance is a non-profit organization dedicated to raising awareness about perinatal mood and anxiety symptoms and disorders and providing support and treatment referrals to women and their families.
If you are struggling or have questions, please call our warmline at 619-254-0023. Our trained volunteers can provide you with support and referrals.
If you need immediate support please call the San Diego Access and Crisis Line at 1-888-724-7240. The toll-free call is available 24-hours a day, 7-days a week
Postpartum Depression International: source of great information about all types of Postpartum Mood Disorders and also offers women resources for where to go for local help. Call or Text our HelpLine
Available 24 hours a day, you will be asked to leave a confidential message and a trained and caring volunteer will return your call or text. They will listen, answer questions, offer encouragement and connect you with local resources as needed.
And take heart, this isn’t one of those “She was in so much pain–” (she was) “– and now her suffering’s ended!” kind of stories, (even though the suffering’s ended, but more on my end) or “It was her time,” “God has a plan”, “It was meant to be,” or any of the other ridiculous platitudes that etiquette has taught us to say when someone is in pain.
By the by, all of those last few statements are damaging. They’re not even worthless, they’re Express Delivery Pain, and they wreck a person who is grieving. Better to say nothing when you don’t know what to say. Moving on.
Naomi was an artiste.
She participated in yoga, dance, performance arts, stage combat and renaissance festivals. Naomi practiced with a few religions and philosophies, loved to read and visit museums. She had a very exotic look (she was born in Russia, and her heritage is of Rom descent), and her tattoos were beautiful. I loved how delicate her skin was, and how her hair shone in the sun. She always managed to look glamorous, no matter what she was doing. Her face was the embodiment of Resting Bitch Face.
Only a few years older than me, but she had some mileage on her. As a teen addict and rape survivor, she’d managed to gain herself a steady income, decent living arrangement, clean and sober (apart from cigarettes; cloves, especially, were her vice). She was very ‘jaded’, as one might say (if one doesn’t have more depth than a teacup). Naomi was ever so much more than jaded; she was downright grisly. She was overripe with experience. Her font of knowledge was brackish water from a sewer system. Naomi had truly seen the underbelly of American Life as a runaway, and it stayed with her.
And yet we became friends. Fast friends, actually. I was only just twenty-ish when Naomi steamrolled her way into my world via social media. We talked for hours sometimes, and both of us liked to draw Tarot for the other. It became a regular thing for me to travel out to the East Coast to see her. I was the maid of honor at her wedding, and her ex-husband (they divorced shortly after, but remained friends) still keeps in contact with me. I met several of her friends, two of whom I have also now flown out to see, separately from Naomi, although we would send selfies to her.
The thing to keep in mind, though, is that over the years, Naomi never put away That Habit that some broken youths just can’t kick: the need for drama.
It makes you feel significant. You feel like you’re at the center of a play that’s only interesting if you’re speaking or being pandered to. When there’s drama, you feel important and like your life is far more tragic, amazing, complicated, full of hardship or whatever else is on the agenda for the day. Cultivating drama and seeking it out in what would otherwise be considered (by many, not just me) very normal, everyday encounters– that’s an addiction for some kids that have fucked-up backgrounds.
I should know. I am one.
Naomi was the kind of person that, if I was sound asleep in the spare bedroom, she would come into my space unannounced, and flump onto the mattress beside me and sigh. LOUDLY. I fell for it the first couple of times, but after she complained that an author friend of ours (who’d allowed us to stay at his home while we were visiting the township together) hadn’t made a move on her, even though she promised to fulfill his every wish, I’d had enough. I needed sleep. So I pretended to stay asleep. She bounced a little more, took off her shoes and said, “I just need to sleep in here tonight.” I made a quiet noise and turned over. “But I guess you’re asleep and not up for talking, huh?” Naomi said this at normal volume, full of petulance. With another anguished sigh, she picked up her boots and stomped to the couch.
One of the many things we talked about, as the best of friends, was nutrition and dietary specifications. We liked to experiment with replacing ingredients to either cut carbs, help out with digestions, etc. Herbs and supplements were never far from our mind to reach for, rather than a bottle of Aleve. We’re not hippies (hippies don’t hate the way we do), but we try to listen to our bodies and respond to small cues. We exhaust other avenues before seeking out a doctor.
She’d had a hard time kicking a bout of thrush, and had had no real success with a limited-ingredient diet. One morning, she called and said, “Uh… my skin is orange?” and I knew, immediately, that she was extremely ill. “Go to the hospital,” I breathed out, “and call me once you’re there.”
Naomi had a very rare form of neuroendocrinal cancer. It essentially starts in your brain and blooms into a tumor in a random part of the body. And the cancer was choking her pancreas. The mass was inoperable, but it responded to radiation, and we hoped to direct the radiation to shrink the mass away from this badly-needed organ just enough to allow for a surgeon to cut away the cancer. Instead, it started to shrink right where it was, and after a shunt was implanted to allow her pancreas to work, Naomi’s body threaded a new artery *through* the tumor, and several other veins as well, so the pancreas could still receive blood flow and remain intact and functional. It was almost as if her body wanted to hang onto the mass, regardless of malignancy.
Once the tumor measured at about the size of a tennis ball, they began chemotherapy. I would fly down to be with her during the week at the suites, and we would lounge with the television for hours together. I’d make her curry, she’d help me craft mocktails, it’d be a nice time. But every single time I visited, she and her husband were fighting. Once, in the middle of a dinner with another friend at the beach, she called me to say that they were getting divorced and she needed me to take my things and go to a hotel. But by the time I arrived home, they were quietly ignoring each other and behaved normally with me. Everything was apparently fine. They divorced shortly thereafter.
When it came time for the annual oncology review, the tumor was still present in the same position, but it also wasn’t getting bigger. As most of her organs were functioning perfectly fine in spite of the tumor, she was cleared to move up the coast to Brooklyn. She invited me to her parents’ house in the country, but I declined. I had just become pregnant with my daughter, and I didn’t want to travel. Naomi said she understood, but there was an edge to her voice.
Within a few months, I can tell you what the vast majority of our conversations were about:
-NYC is filthy
-her roommate is awful
-there are no pretty, single goth boys
-cancer is stupid
-hating her bosses
-hating her job
-hating her new roommate
-hating how she has to beg for attention from a guy she’s dating x6
-hating that nobody is nice to her
-hating the new job
-hating the other roommate, but only slightly less than the newer one, and never saying a thing about it to either of them
There was a notable shift in who she was as a person, and how she interacted with me, after I became pregnant. Perhaps it was because I was no longer available and had had her linked with my Emergency Contacts so my phone would always ring if Naomi called me. At some point, I broke my phone and never set up the Always Ring contacts in the new one. This lead to many impatient messages on the morning after, increasing in resentment the longer it took me to respond.
When my darling baby was born, cheerful and healthy, Naomi asked to be called the witchy godmother, and cooed at my wobbly infant. She sent me pastries from her favorite Jewish bakery, and shipped blankets with chewy spots for the baby. One day she told me that she felt much more attached and close to me and my child than she did her own sister and nephew.
Therein lays our friendship, at its core. We admired and adored the other from a distance, and shared intimate details of our love lives and inner feelings. I had been friends with Naomi for so long, when it became more one-sided, I chalked it up to the cancer and let it go. But I realized that it was just who she was as a person. She would always be the victim, the one who has it worse, who hurts more, who feels things so deeply no one could possibly understand what she’s going through. I began to avoid her questions of, “Do you have time to talk?” and only respond later when I could be more attentive, but by then, the moment (and the drama) had passed.
Finally, when my daughter was 4 months old and I was at the peak of my exhaustion and postpartum depression, Naomi’s gall bladder turned septic and she had to have an emergency surgeon to remove it. I knew she’d been at the hospital for about a week, and her boyfriend was making updates as best he could, but if I’d ever felt the energy to start texting or talking to anyone– not just Naomi– I would always stop before the first sentence left my fingertips. I wouldn’t have time for a conversation, or the energy to listen. I was pretty broken, and my gurgly baby was delightful and adorable and easy to handle but… postpartum depression is a monster. Perhaps I was wrong to think our friendship could survive a month without contact. Maybe I should’ve just sent the one or two-sentence text messages, just to let Naomi know that I was thinking about her.
But I didn’t. And for the better part of 6 weeks, neither of us reached out to the other.
And then she messaged me one day out the blue, opening with, “I am upset and I need to tell you what I’m feeling.” So I settled into Best Friend Mode and prepared myself for an hour or two of new/old complaints with minimal commentary on my part. But I was not prepared for what happened next.
“I almost died!!” she raged, “and you couldn’t even pick up the phone! But I’m just expected to remember every stupid detail about your kid!” and that’s about when she lost me. I’d heard about other people saying crazy things when their cancer gets to late-stage terminality, but I had also become (unfortunately) too experienced with people fighting cancer and then dying. And I don’t find this to be true.
My kid had nothing to do with this fight we were about to have. I tried my best to shelve the comment and look for what was underneath: she was in pain, she had no way of expressing it beyond rage and lashing out. I tried to commit to this conversation with everything I had, and I am still grateful that my kid was napping at that precise moment in history.
I listened and took in all of her words. I filtered out some of the hate and attacking phrases, and sent back a heartfelt apology, with a promise to do better in the future and to at least keep Naomi abreast of where I was emotionally. I apologized again, and said that I would understand if she needed to stay mad at me for a while, but I just needed to say the words “I’m sorry” first.
I’m not sure how everyone else on the planet receives apologies, but for me, all I want to hear is:
-acknowledge the pain that was caused, without excuse
-empathize as to how this could have affected you, were the tables turned
-admit fault, apologize sincerely
-have a plan for what to do differently next time (and/or how you intend to make it up)
Pretty sure I’d checked off all those boxes in my reply, but apparently, that’s not how Naomi liked her mea culpas, especially without a genuflection. I had ended my letter with love, but she instantly shot back, “Spare me diplomatic bullshit.”
I bristled, but was more hurt that she thought me insincere.
“I can see you are still very angry,” I responded, “so I’ll leave you be for now.” I was trying to just give her space to be angry without being more hurtful to me, and I thought I had conveyed that it wasn’t in my intention to block her out or turn away from her. I hoped my words had been received with love on some wavelength. That’s not what happened.
“I’ll leave you be for now.”
“what else is new”
That was over a year ago, in May of 2019. A lot has happened in the last 18 months.
Last week, I discovered that Naomi had been found dead in her bedroom by her parents. The cancer had progressed, she had had another emergency surgery, and she succumbed within a month. Her fight was finally over. Our mutual friends were sharing stories and crying over the loss of such a beautiful person, and what must I be feeling, as the very best friend of olde?
Well.. I felt relieved. I felt a tremendous weight fall away from my body.
Ah, yes, yes, I’m a horrible person, I know. Luckily, I also don’t care what anybody else thinks.
Was it surprising? Yes, of course. I hadn’t been in contact with Naomi for over a year.
Was *I* personally surprised? No, not at all.
Part of being the Best Friend meant helping her plan her will, her final wishes for rites and burial, for palliative care and, in case the worst of it came to pass, her plan for suicide. I had promised to assist. More than once, she used the phrase, “I don’t want to live like this anymore,” and I would comfort her as best I could, without asking if she was ready to die. One day, she told me she was ready, because the pain had become too much. I asked her to give me a day to get my affairs in order, and I’d get on the plane to NYC. By the end of the night, she’d messaged to say not to bother coming out, that she was fine.
When I found out Naomi was dead, I felt a deep pain in my heart for the relationship that we had shared. For the actual friendship, the late night talks, snuggling with her dogs, sharing costumes and garb for holidays and vacations. We loved each other, truly. But not everything is made to last forever.
As I scrolled through the memorials and testimonies that people were contributing in her honor, I felt mildly amused, thinking, “I doubt Naomi ever told these people the things she told me.” And it hit me– I’m glad she’s dead.
No more drama.
No more unnecessary calls.
No more seeking out the worst-case scenario and *betting on it*, in every situation.
No more shrieking, no more “Okay, but just five more minutes–” stretching into an hour every time.
No more pity party the size of Houston.
No more of any of it.
As it would have fallen to me, eventually, to untangle and sort through the mess of feelings she’d stirred together and dumped on me in that final conversation, and try to make sense of our friendship going forward, it still wouldn’t have been enough. Naomi always needed grandiose gestures to make her believe that a person was being honest and truthful. And I have never been the person to do that.
It would’ve been my job to fix that mess, because that’s the way it had always been. Helping her to see another’s perspective, and not assuming the worst intention of her lovers. Reminding her to breathe before she speaks, and never say the first thing that comes to mind. These are behaviors that every grown adult must learn to master for themselves, so they can be contributing members of society.
I was 35 years old before I realized that Naomi was completely dependent on me. I had never realized that our friendship had taken that turn, but looking back, it was so obvious.
I’m so very grateful that she is no longer suffering from migraines, nausea, aching all over and weariness. I am happy that Naomi has passed. Her body was terrible to her. But the emotional hellscape in which she lived, every single day, was the real demon, not the cancer. And it was largely her own doing, because she could never back away from being the center of attention. She had to repeat everything she heard or suspected about a person. There was no irritation too small that she couldn’t launch a full-scale critical review, complete with scathing commentary. If nobody had told Naomi that she was pretty at least once a week, she would post a new selfie with a comment: “felt cute might delete later” and then praise every person who complimented her. The reason I know she did this intentionally is because she told me.
I’m glad she is dead. I am relieved that my friend has died. I am happier because she’s dead; a tremendous burden has been lifted from me.
I don’t even know what her family intends to do with Naomi’s remains, but I’m not going to call them and ask, or insist on carrying out her final wishes. That was a promise I made to a friend. The woman who called me names and vilified me at my lowest point is not my friend.
I’m not obligated to fulfill anything on her behalf. I’ll never have to unravel another one of her messes ever again. I’ve said it before, and I’ll say it again: I’m glad she’s dead.
Post Script: if this kind of thing truly makes your insides twist, I am pleased that there are still people out there who have only experienced wholesome relationships that are full of goodwill and reciprocity. But since finding my voice about this and learning to say how I feel without needing to justify it, it has been made clear to me that many, many other people feel this way about now-deceased people from their pasts, and for far worse reasons than the ones I claim against Naomi. So to those people who’ve only experienced equitable relationships, I salute you. For everyone else, go ahead and say it out loud. I give you permission to say “I’m glad they’re dead,” and then reflect on any good times you may have shared, or at least share why it is that you are glad they’re gone. It has given me tremendous closure. Maybe your family or mutual friends don’t or won’t understand, but that’s okay.
You can say it to me, here, or you can write about it on your own, or you can tell it to The Band. We are here for you. But either way, go ahead and say it, see if it helps free you the way it did for me.
June 7, 2020 at 1:00am, an hour before my shift at work, I got a phone call no one wants. It was my dad: I answered. “Mom died” he said tearfully.
I felt my stomach drop. Impossible. How could she be gone? I was stunned. I immediately stood up, gathered up my work stuff (knowing that I wouldn’t need them that morning) to meet dad at the hospital.
Mom had been in the hospital for a UTI for the past week. Her condition had been stable but she was pretty out of it. Because of the virus we were unable to see her in the hospital or at all because she lived in a nursing home. We had done window visits, and dad talked to her on the phone, but it wasn’t the same. I attempted to Facetime with her (earlier that week) but she was pretty out of it My mom had MS, so her health was always on a roller coaster. I kept thinking how we managed 3 years since the last hospital incident when things were close then. I thought we had more time.
The drive to the hospital (also my employer) was a blur, I was trying to reach family members to let them know what happened. All I knew is that her oxygen levels had dropped. “There had to be more”, I thought. I made it to work hurrying into the office to deposit my keys, tell my coworker where I was going, and grab a mask. I met dad out in the ER and we hugged. Going up to the floor where mom was seemed so unreal, like a dream, a really horrible bad dream. I felt nauseous and almost like I was back in time to when my sister died 7 years ago and we went to see her, then almost 20 years ago when my grandfather died. I was not ready for this.
When we approached her room the nurse was so kind, just explaining what happened (the same thing my dad had said), and the nurse added that mom kept saying “Go away” to her. That gave me indication that she knew it was her time, she was tired, and my sister was waiting for her.