The New Blue

I’m finding it hard to write this. Partly because it’s very personal. Mainly because, as I write, I have a loud whooshing sound in my ears, zaps of bright light attacking the edges of my vision and a throbbing pressure on my head which gets worse when I move my head, walk, lie down or breathe.

I’m currently withdrawing (and believe me, withdrawing is the right word!) from a fairly low dose of an anti depressant – a tablet I’ve been taking daily for about the past year, which worked by inhibiting the receptors in my brain which absorb serotonin (a neurotransmitter linked to mood and sleep), thus leaving more serotonin floating around in my system, and improving my mood. Now, I’ve worked with many people who have taken anti-depressants, and am well aware that withdrawing from SSRIs can sometimes feel worse than the symptoms they were prescribed to treat in the first place. Nevertheless, and despite weaning off them fairly slowly, dealing with symptoms of brain zaps, depersonalisation and dizziness with two small children has not been fun.

But the reason for writing isn’t to warn you about the importance of preparation when coming off SSRIs (the two week child free holiday that would have made this a whole lot easier wasn’t really on the cards!), but because – looking back on last year and starting to reflect on why I needed them in the first place – I’m noticing that there’s very little information out there. We know more these days about postnatal depression, and even antenatal depression, than ever before. But post weaningdepression – not so much.

You might think that, being a psychologist, I’m more immune than most to mental health troubles. But of course, mental health problems can affect all of us, and often feel like they can come completely out of the blue. Despite not having experienced any post natal depression after the births of my children, about a fortnight after weaning my second child I was hit with all the classic symptoms of depression – irritability, tearfulness, low mood as well as all the weird symptoms you don’t necessarily hear about like bizarre dreams, total disorganisation and an inability to string a sentence together without having to really, really concentrate.

The lucky thing about being a psychologist is that I’m relentlessly self reflective. So, I spotted the signs early on, went straight to my GP and referred myself to a psychologist who supported me through it therapeutically, then asked for a prescription for anti-depressants after three months of therapy hadn’t improved things. I’m not sure any of these things would have happened had I (and my lovely other half) not recognised the signs. Despite being aware, I was still told on more than one occasion that I was probably feeling blue because I had ‘a lot on my plate’.

The trouble with diagnosing depression in mothers is that a lot of the symptoms of depression are also symptoms of motherhood. A GP will often give you a standard depression questionnaire to establish the severity of symptoms and to give a baseline measurement, to assess any improvement. One of the most used questionnaires in this country is now the Patient Health Questionnaire (PHQ-9) which asks you to rate, over the past two weeks, how often you have experienced symptoms such as ‘trouble falling asleep or staying asleep, or sleeping too much’, ‘feeling tired or having little energy’, ‘trouble concentrating on things’ and ‘poor appetite or overeating’. I, like many mothers, would have answered ‘nearly every day’ to these four criteria throughout my first year of parenting (and beyond) – which means I would have met the cut off for moderate depression despite having no subjective sense of feeling depressed.

So, as you can see, it’s not an exact science, and – particularly in our incredibly overstretched and underfunded NHS – symptoms of depression are often missed. In my GP surgery, a typical London practice, I often waited for an hour past my appointment time to spend five minutes with a harassed doctor who simply wouldn’t have had the time – let alone the headspace – to spot my well hidden symptoms. Sadly, cuts to Children’s Centres and NHS services including the increased pressure on Health Visiting and midwifery teams mean it is far, far harder now to access that first appointment which can make all the difference. Being parents also adds an extra complexity to ‘confessing’ our true experience – many fear that their capacity to parent their children may be questioned, leading to Social Services involvement. While this is unlikely to happen, the fear of this can stop many mothers from seeking help at all.

I know, from both work and home, how well women hide their feelings, how many mums are sitting in Baby Rhyme Time smiling over an aching heart. There are those who eventually brave an open talk with their GP and (hopefully) receive support. And there are many more who just live with it and wait for it to pass.

If you’re reading this and nodding in agreement – I would urge you to please please PLEASE talk to someone – your GP is your best bet, but perhaps you have a good relationship with a Health Visitor, or someone in your local Children’s Centre. You can also self refer to many primary care psychology services, or you can access private help (don’t be put off by the cost, many therapists offer low cost services too). And please remember that the NICE guidelines (the evidence based guidelines offering advice for treatment) for mild and moderate depression emphasise that psychological intervention should be offered as a first step, and for mild depression actually advise avoiding routine anti depressant use. In other words, make sure you get referred for therapy and not just given tablets – the tablets may help but it’s the therapy that will resolve the depression.

 

But I didn’t just want to talk about depression, I particularly wanted to talk about depression after weaning. Because it’s this that – despite three years of an undergraduate psychology degree, three years of a doctoral training in clinical psychology and three years working almost exclusively with mothers – I had never, ever heard of. And it’s not surprising really, because on searching for studies on weaning and depression, I could find a very small handful. In fact, most studies relating breastfeeding and depression concentrate on depression’s role in ending the breastfeeding relationship, rather than the other way around.

This isn’t a post to discuss the relative merits of breastfeeding, or the challenges women face in establishing a successful breastfeeding relationship. These topics have been covered extensively elsewhere, and experts such as kellymom.com and La Leche League can answer such concerns far better than I could.

But, once you do manage to breastfeed a child, you eventually face the challenge of how to stop breastfeeding that child. This is an area where advice is less forthcoming. And if your child has been exclusively breastfed, refused bottles and frequently ‘snacked’ on the breast during the day (as many do), the usual advice to just ‘drop a feed at a time’ doesn’t really fly. Having successfully breastfed, and hopefully got to the point where feeding is second nature, you’re left with a choice whether to continue to breastfeed until your child feels ready to stop by themselves, or to find a way to end the breastfeeding relationship often against their (very strong) will.

 

The challenge of weaning alone is a potential stressor that could lead to depression, alongside the emotional fallout of ending the breastfeeding relationship, which is itself an enormous transition. I was lucky to have the support of a fantastic group of mums to help me manage weaning. But aside from the emotional side of things, there is a huge hormonal fallout too. In fact, the hormones involved in breastfeeding could have been one of the reasons I was lucky enough not to experience postnatal depression. Having been pregnant or breastfeeding for four years, I now wonder if the drop to pre-pregnancy hormone levels (specifically, the drop in oxytocin and prolactin) triggered an episode of depression for me.

When you start to really explore hormones in the postnatal period, things get rather complicated. Of course they do, we’re talking about the human body here and we know it is capable of marvellous and terrible things. In the 15 or so years that have passed since I first heard about oxytocin, I fully accepted it’s status as ‘the love hormone’. I assumed all women have similar levels of oxytocin, that it can be affected during birth by feeling unsafe, that it is raised during breastfeeding and plays a strong role in bonding with your baby. Oxytocin = warm and fuzzy.

Simple, right?

But we women are complex and mysterious beings, and I should have known that oxytocin would be a bit more complicated than that too.

It turns out some women have much lower levels of oxytocin than others, which can be measured in pregnancy and could even predict post natal depression (indicating that treatments focussed on oxytocin during pregnancy could prevent depression after birth….this also makes me wonder if women with lower oxytocin levels might have a greater chance of difficulty during birth? Google is telling me nada)

There is also some evidence that oxytocin in certain people, far from bringing warm and fuzzy feelings, actually increases a stress response.

And considering our general cultural propensity to ‘get things done’, the speed at which we wean could also increase chances of depression occurring. Weaning gradually, to prevent a sudden drop in hormones, could also prevent a dip into depression.

I’ve always baulked at the idea of a purely biological view of depression – for me, and keeping in mind the many women I’ve worked with over the years, depression has always been the product of a complex interplay of factors. In relation to weaning, the La Leche League as ever say this much better than me –

The physiological process of weaning is complex and involves microbiological, biochemical, nutritional, immunological, and psychological adjustments for both mother and child.

This also highlights to me the ever complex interplay between a mum’s and a baby’s needs, because our children too will experience changes due to weaning. And we must be mindful of preventing and treating depression not only to help mothers, but also to help their children.

So, while I firmly believe in a holistic approach to depression, ‘environmental’ reasons are often looked for when actually a biological or physiological reason may be staring you in the face. Of course, the biological reason may create environmental reasons so it’s a bit of a tangle. But every reason needs to be listened to and understood. Sometimes when women talk about their sadness or worry there is an expectation that this is just one of those womanly things that we have to deal with – our pain isn’t taken seriously. I do wonder how different my own experience would have been if I’d been asked just once whether I’d recently stopped breastfeeding, and the different avenues to improving my mood this would have opened up.

Sometimes there is a purely biological pathway to psychological difficulties, or at least the biological path is the first point at which improvements can be made. For example, the limited research into hormonal influences on depression in the post natal period (including weaning) highlight the immune system response, and suggest that simple remedies such as Omega 3’s and St Johns Wort can support mood. And, of course, knowing that a dip in oxytocin will occur during weaning, we can also make sure we build oxytocin activities into our day – such as the long cuddles and kisses our newly weaned offspring will also appreciate!

Despite being so well informed about depression (and mental health issues in general), there is still such a lot we don’t know – and still such a strong propensity to dismiss women’s sadness as inevitable. I could write a lot here about why we shouldn’t accept this, and how little help we get as parents in modern culture which makes an emotional fallout almost impossible to avoid. But that’s another story. Instead, maybe it’s enough to say – you know yourself. We know ourselves. As women, as mothers. As mothers particularly, we can hone in to our instincts like never before. And rather than shying away from our struggles, singing along at Baby Rhyme Time, we can share them.