Breastfeeding and medication

Recently, I was talking to someone on Twitter about breastfeeding on (and after) antidepressants, and it hit me once again how big a role breastfeeding can play in a woman's decision whether or not to seek treatment for PPMD. For me, among other fears (such as my child being taken away from me), I was so far into the whole "Breast is best" mindset that, when the filter of PPMD was added to the mix, the idea of having to stop breastfeeding my baby was horrifying and extremely upsetting. Concern over having to stop nursing is one that I frequently hear/see brought up and it is totally understandable.

I have written a couple of blog posts in the past about why Breast is not always best (part 1 and part 2). That is not going to be my focus for this blog post. In this post, I'm just going to share what my personal experiences have been with breastfeeding and medication.

When I was admitted to the hospital with a diagnosis of Postpartum Depression, my baby was 3 months old and exclusively breastfed. I had held off on getting help but finally realized I was at a crisis point and went to the ER, where I was transferred and admitted to a psychiatric facility. Because I specifically didn't want to have to stop nursing my baby, we tried talk therapy for the first day or two, but I could hardly even open up about how I was feeling and we quickly realized that medication was necessary. They started me on Lexapro (I was soon switched to Celexa, a generic version, for Insurance reasons), Ativan, and Ambien, which are not considered "safe for breastfeeding", so I had to stop nursing. I was extremely upset, but accepted that if I wanted to get better, this was what needed to happen. My baby did fine switching over to formula and the only discomfort was on my end because I stopped nursing/pumping cold turkey (ow, ow, ow). 5 years down the road, my daughter is extremely smart and well-adjusted, and we continued to bond very nicely. Actually, I think we bonded better because I was on medication and was able to connect better (I definitely remember the connection better after starting medication).

That first admission, diagnosis, and start of medication were in July 2009. At the beginning of December 2009, I was diagnosed with hypothyroidism (my doctors had previously missed it, but that is a whole different story for another time). Pregnancy can cause hypothyroidism, and hypothyroidism can cause mental and emotional health problems. I was promptly started on a low dose of Levothyroxine, a thyroid hormone replacement medication, and started to see my symptoms lessening pretty immediately. My dosage only had to be adjusted once to get my TSH and T4 levels back to within normal limits, and that also kicked the rest of the PPMD symptoms. After 3 months of Levothyroxine, I was able to stop taking the Celexa, Ativan, and Ambien that I had been on since July, and all was well.

I have been on this same dosage of Levothyroxine for 5 1/2 years now and it has never needed adjusting. During my pregnancies, the OB monitors my thyroid levels with bloodwork once a trimester (more often if I start experiencing anything unexplained  that could be symptoms of my thyroid medication needing an adjustment), but so far everything has been fine.

In April 2011, I gave birth to our second baby. Even though we were sure the PPMD had been related to the hypothyroidism, at my midwife's recommendation, I started taking Zoloft at 38 weeks pregnant (read what the Mayo Clinic has to say about antidepressants during pregnancy) as a prophylactic measure, and weaned off of it at about 6 or 7 months postpartum. This was shortly before finding out that, much to my shock and attempts to prevent pregnancy, I had another bun in the oven.

That second baby nursed through Zoloft, Levothyroxine, and the first two trimesters of my third pregnancy. She finally weaned herself at about 13 months. I was about to force her to wean since she had started biting (yay for teething). Let me tell you, I thought getting a tooth to the boob was painful enough under normal circumstances but with pregnancy making the girls extra tender? Yeeeeeeeeah.... "ow" doesn't quite do it justice. But, at that point she was down to usually only nursing in the middle of the night and she weaned herself, so it all worked out happily for both of us.

I started on Zoloft again at about 35 weeks with my third pregnancy. The original plan was to wait until 38 weeks again but I had some symptoms of depression and anxiety that were due to situations that were going on totally unrelated to pregnancy and we thought it best to start the Zoloft a little early. Baby #3 was born in September 2012. I was able to come off the Zoloft at about 3 or 4 months postpartum that time, again with no issues. The only issues I had were when I started using the Nuva Ring and got super tired (plus some intrusive thoughts) but that all went away when I discontinued the Ring. Baby #3 was EBF until I started school fulltime when he was ~4.5 months old. At that point, I got a good double electric breast pump and started pumping so that he got exclusively breastmilk at daycare and EBF when he was with me. With my school schedule and everything else going on in life, the pumping got to be a bit too much and eventually I stopped pumping; he got formula at daycare and breastfed when I was around. He self-weaned at 9 months.

I've done a wide range of options for feeding my children. Exclusively breastfed, Formula fed, breastfed through pregnancy and a little past the first year mark, breastfed plus breastmilk in a bottle, and breastfed plus formula. I've nursed on different medications and off of them. There is no shame or failure in any of these methods that I chose to feed my children. At the end of the day, what matters the most isn't *how* I fed my babies but *that* I fed them.

My experiences and feelings may not be yours. I can not say what is right or wrong for you and your family, aside from telling you that taking care of yourself is absolutely right, and that anyone who looks down on or tries to shame you for how you feed your children is 100% wrong. What I can tell you is that you are a good mother no matter what method (or combination of methods) you choose to feed your baby[ies]. In order to take care of others, we have to take care of ourselves first and practice radical self respect. Self-care is vital to not only our own well-being but the well-being of our babies and our families.

Whatever your choice, make it and don't let anyone get you down. If they want to say that they don't approve or agree or whatever, you feel free to send them on over to me and I'll gladly have a friendly chat with them.

I would not take any of these drugs

Welcome to the second post in my series This So-Called Disease. In the first installment, I talked about the person who left this comment on someone else's status about Zoloft vs. Celexa.

In that first post in the series, I touched on how the use of the phrase "this so-called disease" and others like it trivialize and make light of mental health in general and Postpartum Mood and Anxiety Disorders specifically. I'm still seething about that...

In this post, I'm going to examine the first sentence of this comment and try to express how it makes me feel as a survivor of Postpartum Depression, Postpartum OCD, and Postpartum Anxiety.

"Pardon me, but I would not take any of these drugs."

When I think of how I would respond to someone saying that, I'm torn between "That's nice. Good thing I'm not you" and something slightly less snarky. In my experience, people who say things like this usually respond to a smartaleck response with something along the lines of getting offended and huffing about "Well I'm only trying to help" or "You don't have to be so rude". Alright. First off, it's rude of YOU to come in here and tell me "I wouldn't take that" and act like you know every facet of my situation and medical history, and the factors my doctor and I are looking at. And that's without even starting to look at how incredibly rude it is to make light of someone's illness and basically blow them off. So don't go firing the first shot and then be upset when the person you've just gone after on a very sensitive topic shoots back.

If I were a better person, my first instinct would probably be to respond with something more along the lines of "Thank you for your input but my doctor and I have decided that this is the best course of action for me. Here are some facts and statistics about Postpartum Depression and mental health. Let me educate you.". But by golly, it gets so frustrating to constantly and continuously hear people who have never been in your shoes tell you that they know better than you what you're going through and how you should handle it.

When someone tells you something like "Pardon me, but I would not take any of these drugs", it's very easy to feel like you're being told that you're making the wrong decision and doing the wrong thing. Considering that when I was fighting this nasty battle, one of the worst parts was my brain telling me that I was doing everything wrong and I was a colossal screw-up, I sure as heck didn't need other people (who didn't really know what they were talking about) telling me what I was doing wrong or what I should do better/differently. I was already beating myself to a pulp,; I didn't need any outside help taking a hammer to me or even handing the hammer to me.

On top of that, you're not me. If you've never been in my shoes, you can't know what you would or wouldn't do if you were me. You can THINK you know, but you don't. Not really. Until you're inside my head and my heart, feeling what I feel, thinking my thoughts, seeing things the way I do through my lens of PPMD (and everyone's lens is a little different, no two people have the exact same filter), you don't know, so stop trying to tell me what YOU would do and try supporting me,

If you really feel that your concerns about whatever treatment I'm considering are that big that you really have to say something, do some research first and then come to me privately and say "Hey, so I have some concerns. Here's what they are, here's why I feel this way, and here's what I found when I looked into it. I'm not trying to tell you what to do. I just want what's best for you and I want you to know that no matter what, I love and support you and I'm always here for you.". Do you see the difference?

It's been my experience that people don't usually like to be told that they're wrong, even about small things. When it comes to something as important and sensitive as how they're considering or choosing to treat an illness, it's even more so.

I don't know many people who go into decisions about things like mental health treatment and antidepressants lightly. I know the person this comment was directed towards certainly isn't. I definitely didn't; not when I was hospitalized the first time, not when I decided to take Zoloft starting at 38 weeks when I was pregnant the second time, and not when I decided to start Zoloft at 35 weeks this last time instead of waiting until 38 weeks. None of these decisions were made lightly. They were all made with a great deal of research and talking to my husband, my medical professionals, and friends who had dealt with similar situations. In my opinion, it is the height of arrogance to set yourself up as an authority on the decisions a person is making about this type of thing when you are anything but, and to tell them loftily "Well that's not what I would do". Not only do you set yourself up to potentially lose a friend and make yourself look like a complete jackass in the process, you can potentially do a lot of damage to the person you're giving this "advice" to.

You wouldn't take these drugs? That's nice. You're not me. You don't know what I'm dealing with. And you're not my doctor. So until you can be supportive instead of being a jerk, just take this particular piece of advice and shove it. I won't tell you exactly where to shove it, I'm sure you can figure that out for yourself.

2 weeks and a lifetime later

Happy (slightly belated) 2 week birthday to my little man. We're settling in nicely at home. My hormones have settled down for the most part; now when I have mood swings I can usually see a correlation to how much sleep I lost the night before and how crazy the kids are being. Elizabeth informed us the other day that I'm a "little elephant" and I didn't burst into tears or otherwise meltdown. This is a definite improvement.

As I think back to January, when I first found out I was pregnant, it doesn't seem possible that it's been 8 months (I was late finding out I had a bun in the oven). It seems more like it's been an entire lifetime. At that point, I couldn't even believe I was pregnant, much less be excited about it. The news was totally unexpected. You always hear that contraceptives are 99% effective but you don't expect to fall in that other 1%. My copy of What To Expect When You're Expecting didn't exactly cover how to cope or adjust. None of the pregnancy books I read did. They talked about the happiness and joy of expecting a new baby but didn't get in to how to deal with feeling like you don't want a pregnancy you've found yourself in unexpectedly after trying to prevent it.

To say it was a shock would be something of an understatement. I cried and they weren't happy tears. I had just weaned off of the Zoloft I had started taking at 38 weeks pregnant as a precaution against PostPartum Depression. My youngest was 9 months old, I wasn't even out of the "danger zone" for PPD. I was still losing baby weight and had just gotten back in to clothes without elastic waistbands. I had plans for all sorts of things I wanted to do that were now thrown out the window or put on hold for an unknown amount of time. It took a while to get past the surreal feeling of "This can't be real. I'm not actually pregnant." and to accept that yes, I was in fact heading straight back in to maternity clothes. The entire pregnancy was a roller coaster of emotions.

And yet, I look at my baby and now I can't imagine life without him any more than I can imagine life without either of my girls or my husband. It's incredible to me that I've come full circle. For most of my pregnancy I was scared that I wouldn't bond with my son, that I would feel disconnected or something because of how up and down my emotions were, how upset I was to be pregnant, and how long it took me to even accept that I WAS pregnant, much less be excited about it. That hasn't been the case at all. It's been a bumpy road and an incredible journey with a lot of emotional twists and turns, but I'm happy with the destination I've arrived at and I look forwards to a new and incredible journey and destination with our newest family member. In the beginning, I didn't see how the birthing day could be a wonderful day but it was. It was one of the 4 best days of my life.

Lady sings the (baby) blues

Today, I'm sad. And mad... and grumpy, angry, cranky, happy, irritated, and gloomy, depending on what minute you catch me in. I've cried at the drop of a hat, been laughing 5 minutes later at an e-card a friend sent me, and been in tears for no apparent reason 30 seconds after that. I've been on an emotional roller coaster the hormonal equivalent of the famous real-life roller coaster The Cyclone on Coney Island. Straight up, I have been a mess today. My eyes are red and puffy, my nose is stuffy (and a little raw from wiping), and I have that good old Crying Headache. If you looked up "Mess" in the dictionary, you'd probably find my picture. Why? Simple... I've got the Baby Blues.

"Baby blues" is a term used to describe the mood swings that new moms may experience in the first few weeks after giving birth. According to the American Pregnancy Association's information page about the baby blues,

"approximately 70-80% of all new mothers experience some negative feelings or mood swings after the birth of their child". 

The baby blues themselves are not an uncommon experience for new moms (and yes, you are a new mom after the birth of every child, no matter how many times you've given birth before). As long as the baby blues aren't accompanied by symptoms such as thoughts of hurting myself or my baby, and they go away by 2-3 weeks postpartum, there's really no need for me to be concerned unless I or someone else feels like it's just getting worse and/or staying bad all the time instead of  being an ebb-and-flow type thing. I'm already on Zoloft and have been since I hit 35 weeks pregnant. The baby blues, although commonly confused as being the same thing as PostPartum Depression, are not PPD and while it sucks to be up-and-down, is not necessarily a cause for me to be concerned.

I know the facts, I know the statistics, I know "The drill". Call the doctor if things get bad, don't be afraid to reach out for help if I need it, don't hesitate to talk to my friends and family about what I'm feeling, it's all perfectly normal, etc. etc. etc. I wish it were that easy, though. Because of what I went through with the PPD after Elizabeth was born, I tend to be a little on the "overly vigilant" side of things, super aware, shall we say, of my moods and emotions with regard to mental and emotional health.

It's hard to have days like today and NOT immediately go "Oh my gosh, what if it's PPD again!". You try and you try not to let fear run your life but sometimes, it kicks in and you start to worry. So here I sit, hoping that typing out this blog post will help me to process what I'm feeling and refocus on the fact that what I'm going through is normal and I don't need to go check myself into the hospital.

I'm lucky to have some great friends and family. I posted about how I was feeling ("Baby blues: like PMS on Steroids" was my Facebook status) and immediately had people giving me support and encouragement. Some of the wonderful ladies from #PPDChat hit me with the same. My mom got home from the grocery store and gave me a huge hug (I'm about to start crying typing that but I suspect that has as much to do with her flying back home as with anything else). My husband brought me supper and a drink and was just his usual sweet self, taking care of me. One of my cats came and loved on me. Some of my friends jumped in with dumb jokes and funny e-cards to cheer me up.

It's that type of love and support that keeps me going, that helps me get through the rough patches. That type of encouragement reassures me that I'll be okay no matter what and that my dramatic feelings of... well, dramatic maudlin-ness, will pass with people loving on me and holding me up when all I want to do is to collapse and wail "I hate the world!". And then, there's the knowledge that it really is okay to just hole up in my room, bury my face in a pillow, bawl my eyes out without even being sure of why I'm crying in the first place, and then go blow my nose and eat an ice cream bar or 10.

You do what you have to get by and try not to feel bad about it. It's easier said than done but it can be done. The baby blues suck but they're not the end of the world, they're not the same thing as PostPartum Depression, they don't mean I'll end up with PPD again, and they really will go away. All I have to do, all YOU have to do, is hang in there and keep on keeping on, trying not to beat ourselves up in the process. Because really, there's nothing to beat ourselves up for. We have no control over what our bodies do as far as hormonal changes, it's not our fault, and there's nothing wrong with us. At the end of the day, we're still humans and moms and nothing we feel can ever change that.


To learn more about the baby blues, I recommend these links.

• http://www.babycenter.com/0_the-baby-blues_11704.bc
• http://www.americanpregnancy.org/firstyearoflife/babyblues.htm
• http://www.marchofdimes.com/pregnancy/faq_whatarebabyblues.html

I started on Zoloft a little earlier than I had planned.

The plan for me, with my history of PostPartum Depression, was to start taking Zoloft at 38 weeks like I did with Miriam. A couple of months ago at a checkup, I talked to the midwife about whether I should start it sooner because I was having some mood wonk. She said that as long as it was up and down mood stuff it sounded like normal reactions to stress/hormones/exhaustion/kid shenanigans etc. The agreed upon plan was that if, at any point, Eric and/or I noticed it was devolving into a down-down spiral, I felt like it was getting to be too much to handle, etc., to let them know and they'd start me then, she made a note in my file and talked to the OB about it so that even if I called between appointments they could go ahead and call in the RX then and there.


I'd started to wonder if I was going downhill. My emotions are out of control, I've started having abnormal anxiety, etc. Well, then the other night Eric told me he was seeing that I had in fact gone into a down-down-down and he thought I should talk to the doc about it. So, I did, at my OB appointment (which happened to be the next day). She sent in the RX then and there, talked to me about the medication itself and how long I should plan to be on it at a minimum, potential side effects of irritability for the baby in the first few days of life and how to cope, etc. I picked up the meds and started taking them last night. I just got my third trimester labs done (they check my Thyroid levels once a trimester) and that all came back WNL so it's not a thyroid thing at this point.


I've got so many conflicting emotions about this, and most of them I know are false thought patterns that I "know better" than to buy in to, like feeling guilty for not being able to handle everything without needing medication, or thinking "What is wrong with me?". And then part of me is going "You're so dumb, you blog about PPD and mental health, you're an advocate for women with PPD, why is it so hard for you to accept the things you believe and tell other women?". It's not really surprising though, partly because the stigma surrounding mental health and Antenatal Depression/PostPartum Depression and lack of understanding/education about them are still SO strong, and partly because in general I suck at taking my own advice.


It's scary.

There's such a thing as being overvigilant

Sometimes recently I question whether or not I might be struggling with PPD again or with Postpartum OCD. I look at the fact that I'm irritable sometimes, having trouble sleeping at night, get aggravated and frustrated, and ask myself "Could these be warning signs?". The other day at the mall I started to have a meltdown, like actually had tears coming out y eyes (just leaking a little, I pressed it back in) and started to think (Do I need to go to the ER?". I tell myself that yes it's all stuff that could be warning signs of a deeper problem, but that it could also be perfectly normal reactions to stress (of which I certainly have an abundance right now) and the fact that due to several outside factors, my sleep schedule is ALL out of whack. Then I start to question whether I might just be in denial and finding ways to rationalize that no, I couldn't possibly have PPD. It's a vicious cycle of never-ending questions that go in a big circle ad nauseum.

The thing I keep coming back to is that I don't have thoughts of harming myself or others, and the fact that I'm aware of the potential and keeping an eye on myself is a good sign, that at least I'm aware of what's going on. I have to talk to a therapist anyways since I've been on Zoloft as a prophylactic measure, so of course I'll discuss all of this with them and request that they recheck my thyroid levels, but it made me think of something.

I think that for those of us who have dealt with PPD, one of the big problems in subsequent pregnancies and postpartum periods can be a sort of hyper vigilance, being TOO aware and almost jumping at shadows. Yes, it's good to be aware of how you're feeling, but I have to keep reminding myself of what Jan, my midwife, told me at my 6 week postpartum checkup. She said, to paraphrase because I can't remember exactly how she worded it, "You have to bless and release the past and live in the future, moving forwards instead of staying in the past". I have to remember that if I concentrate all my time and energy, or even a significant portion, on whether every tiny little thing could be a symptom of PPD, I'm liable to talk myself into it. Life will be so much more enjoyable if I can remember to focus on the here and now and the future instead of what happened 2 years ago.

The moral of the story, I guess, is to reind myself and anyone reading this, to be aware but not so aware you forget to live.

I started Zoloft this week

I'm now 38 weeks and 4 days. I have 9 days left until my due date. So far, my thyroid levels have stayed under control and so have my weight and my hormones/emotions. Well, as much as hormones/emotions stay under control in pregnancy. LOL My perinatal doctor continued to check my thyroid levels every 4 weeks all the way through pregnancy and since my levels were normal at my 36 week check-up, I won't have to see him again. Yay for normal levels!

My midwives started me on Zoloft this week. It's an antidepressant (an SSRI) that is safe for pregnancy and breastfeeding. I haven't had any symptoms of depression but we're doing it as a preventative measure. I suspect that as long as we keep my Thyroid managed, I won't have any issues with PPD but I'd rather be safe than sorry and to know that I did everything possible to avoid issues this time around.

It was actually a hard decision for me, whether to start Zoloft or just rely on the thyroid medication. I know, I know, it should be a no brainer to take it right? The problem was, I felt like starting Zoloft made the possibility of having PPD again seem that much more real. Sort of like, if I ignore it and don't treat it it's not really a threat and won't happen. I didn't want to take it and remember the place I was at before, when I did have PPD last time. The deciding factor for me, after wrestling with the decision, was when a girl I knew from an online forum killed herself. It was sort of a slap in the face, a reminder of what depression can do from an outside perspective instead of just looking at it from "what did it make ME feel". It was also a reality check that "Hey, this is nothing to play around with.". I came to the conclusion that nobody will judge me or look down on me for taking it, and if they do then they are probably not someone I really want to be friends with... but you better believe that before I say Adios there'd be a little chat about PPD and the effects it can have on the mom, her family and friends, every aspect of her life, and how the stigma attached should not be there and how no it really doesn't mean someone is crazy or any less of a human/woman/Christian/whatever.

29 weeks update

I'm 29 weeks and change. So far my thyroid has stayed beautifully under control, my dosage hasn't had to be adjusted at all. I see a perinatal specialist once a month to have my thyroid levels checked and they do an ultrasound at the visits too, it's been really neat seeing how the baby has grown.

I'm getting to the point where I think a lot about PPD. Not obsessing over it, but reviewing warning signs and symptoms, reminding myself that no matter what happens everything will be okay, reminding myself that I am more educated and so is my family, going over my own "safety plans" such as "If I notice myself getting in the doldrums I will tell someone and ask them to help me get help", reviewing who my support system is. I also decided after talking to my midwife that I want to start Zoloft at 38 weeks just to be on the safe side. I really think that keeping my thyroid monitored is going to be the key this time, but I'd rather know that I am doing everything I possibly can to prevent it.