I Am Trained to Diagnose Depression, Yet I Overlooked My Own Amidst a Rock Bottom Pregnancy

Guest post by Colette Delawalla

Gustav Klimt - Hope, II

My name is Colette. I’m a first time mom at 29 years old. I’m also a second-year Clinical Psychology PhD student with an MA in Clinical Psychology and an MS in Quantitative Psychology. I do clinical research. I’ve read the literature on depression. I see clients with depression. I’ve been trained at a graduate level by three different universities to spot depression. And I’ve experienced it at length myself. Yet, when depression reared its ugly head during my pregnancy, I missed it. Or perhaps I refused to see it. We talk a lot about the postpartum period being the single largest hormonal drop a person can experience, but we rarely speak about the 9-month ramp up to that drop and the havoc it can bring to the lives of some expectant mothers. Our society does not make space for women to adequately express the depth of the experience—an experience that is, for many, downright awful.

My husband and I are very “Type A” people. We knew we wanted a child, and we wanted it done a certain way. We set and met financial goals, career goals, and relationship goals before we started trying to conceive, and much to our delight, it happened rather quickly. I’ll never forget the morning when that second line appeared. But, just as quickly as I was filled with excitement, I was filled with dread. I had watched many friends experience miscarriages, and this pregnancy felt like it happened way too easily—surely it would end in loss. Shortly thereafter, the “morning” sickness set in. Morning sickness is such a cruel way of phrasing what actually ended up being an all-day, all-night, all-pregnancy sickness. I would lay on the sofa with my bucket, ice water, and small, bland snacks, counting down the hours until my second trimester, simultaneously hating every wave of nausea but grateful for each one because it meant I was still pregnant. 

At our seven week ultrasound to confirm the pregnancy, my doctor found a rare uterine abnormality that meant the pregnancy was high-risk and increased the likelihood of every bad thing (e.g., early loss, second trimester loss, stillbirth, preterm labor, breech presentation, uterine rupture). This felt like the second foot dropping–of course I was bound to have a tragic loss as soon as I began to get attached to my little blob. In addition to this fresh hell of anxiety, the pregnancy symptoms were piling up. I experienced all manner of symptoms, from annoyances to absolutely awful affairs–such as my eyes changing shape, gums bleeding 24/7, bloody noses, horrid burping, aversions to all food, headaches, exhaustion, brain fog, awful nausea and vomiting… the list was long. I felt so out of control of my body and mind. 

Because of my high-risk pregnancy, I had double the normal number of doctor appointments. The days leading up to each appointment were always rough, because I was so scared this would be the appointment when they put the doppler on my stomach and didn’t hear a heartbeat. At one appointment I cried with relief when my little guy’s heartbeat was a perfect 140 bpm, and my doctor stopped everything and screened for depression and anxiety. He offered to write me a prescription for Zoloft (Sertraline), but I told him I was fine and under the care of a great psychologist. This was the first of two times I was offered a medication prescription to help manage my worsening mental health; both times I refused. Looking back, I believe I likely would have benefited. However, conflicting information about the safety of antidepressants during pregnancy and my own guilt about exposing my unborn son to these medications because I “couldn’t tough it out” stopped me. Perhaps if my doctor had spent a bit more time addressing the safety aspect of medication use during pregnancy, I may have been convinced. Further, I was seeing an excellent psychologist about once a month for therapy. We worked together to develop a plan to monitor for postpartum depression, and she was aware of the challenges I was facing during pregnancy. However, I could never find the right words to articulate my inner experience, and I’m not sure she knew how bad it got for me until our first postpartum session, when I was able to fully express the depth of my depression during pregnancy. And if she did have an idea, maybe I would have accepted that I was depressed and needed treatment had she been more forward about her understanding of my challenges during pregnancy?

My second trimester gave me brief relief from the nausea (8 weeks to be exact) and a little bump of energy. I cleared big milestones and began telling people about the pregnancy. I had a cute little bump; I was “glowing” and really felt like I was turning the corner into the fun part of pregnancy. The third trimester hit me like a freight train. In addition to a resurgence of nausea and vomiting, I was experiencing extreme heartburn—it was so intense that water and plain white rice were barely tolerable even with prescription medication. I struggled to breathe due to the baby’s positioning and growth. My body overproduced relaxin (the hormone that loosens one’s connective tissue so the hips can come apart for birth), such that I not only lost an inch in height, but also experienced symphysis pubis dysfunction (SPD) as well as bone-curdling rib, back, hip, and knee pain. I had what the doctor deemed an “irritable uterus,” causing me to have 30–40 Braxton-Hicks contractions a day, beginning around 25 weeks. Between the physical symptoms and the onslaught of worry and anxiety about the well-being of my baby, I was hardly sleeping. After being hospitalized with a kidney infection, a false labor alarm at 30 weeks, and sobbing to my doctor about my pain even after seeing a pelvic floor therapist, I was put on modified bedrest for the final 6 weeks of my pregnancy. This was a huge relief, both physically and mentally, but I’ve never been one who does well cooped up. In fact, “doesn’t do well” is an understatement–bedrest was my Yellow Wallpaper. This relief was inherently miserable and came at a great cost. 

At one point during my third trimester I participated in a research study where the researchers included a screening for depression and anxiety. By this point, my physical symptoms had me feeling miserable, and I failed that screener with flying colors. The study staff sent in a clinical psychologist, who explained why she came in and wanted to share resources. I explained that I was a clinical psychology PhD student, I knew what was going on, and I was under the care of a psychologist. In my—admittedly overconfident—mind, I wasn’t just a layperson with limited knowledge of psychological issues; I did this for a living. I knew what depression looked and felt like, and to me, this wasn’t it. Notably, I also explained that my symptom endorsements on the screener were normative reactions to my pregnancy. 

Here was my line of thinking with regard to why I did not meet diagnostic criteria for depression:

• Depressed mood: Yes, I felt like shit 95% of the time. I was nauseous and one second away from puking 24/7. I was in a lot of pain, worried about my baby, and feeling like I couldn’t keep up in any part of my life. I was most assuredly feeling depressed.

• Loss of interest/pleasure: Most things that used to give me pleasure (e.g., going for a walk, working, eating, dressing up, painting) were painful or extremely difficult because of my brain fog, which was discouraging. I didn’t want to go out with friends, because I experienced car sickness and was afraid to get sick in public. I was struggling to get the nursery together—a notable change for me as I normally love design and take great pleasure in it—because I couldn’t make decisions and nothing felt right. I didn’t really want to do much, but in my state, I thought, who would? 

• Weight/Appetite changes: I had to eat bland food that didn’t make me sick, otherwise, I would be ill for days. Also, weight change is an expected aspect of pregnancy, which made it easier for me to justify why this didn’t count.

• Sleep changes: insomnia is an expected symptom of pregnancy. As is waking multiple times a night to use the bathroom. I went from sleeping eight or nine hours a night to no more than five. 

• Psychomotor agitation/retardation: Everything slowed way down. I was slower at everything I did, but I had to be. My body and brain did not allow quickness. But, yet again, this was to be expected within the context of pregnancy.

• Fatigue: This was linked to sleep changes…and also, it’s normal to be fatigued during pregnancy. 

• Feelings of worthlessness/guilt/hopelessness: I looked around at the other pregnant women near me who were “glowing” and felt like a complete wimp. I felt like I was complaining too much. I felt so guilty for voicing my bad experience when I really wanted my baby and there were families struggling with infertility. I felt incapable of continuing on and dreaded actually having my child, which I was told would be way harder than pregnancy.

• Decreased concentration: This one was tricky because “pregnancy brain” is another “normal” thing during pregnancy. But to make matters worse, as an individual with ADHD, I was not able to take my usual medications to help with attention and concentration, and I couldn’t drink caffeine because it upset my stomach. So, this was ambiguous. Not to mention the fact that it is rather difficult to focus on things going on around you when you are concerned your baby has died because you didn’t feel them move in the past hour, or you’re so nauseous you can’t think straight, or you’re in pain and can’t get comfortable, or you’re having your 9th Braxton Hicks contractions that hour…

• Thoughts of death/suicide: Ah, the intrusive thoughts. I thought about death and dying constantly. I had thoughts about jumping off my balcony, getting into a plane crash, dying in childbirth, my husband dying in a car crash, being killed in an armed robbery. You name it, I thought it. But, during such a pivotal time of change and vulnerability, I discounted these thoughts as par for the course. Of course my brain wanted to warn me of potential bad outcomes, “That is the brain’s job”.

As I went through these symptoms, my interpretation was that I was experiencing understandable reactions to my very difficult pregnancy and anyone in my shoes would be experiencing these symptoms. Unlike past bouts with depression and anxiety, these symptoms had such an obvious cause that I simply and mistakenly discounted them. Besides, I had all the protective factors against depression! I had an incredibly supportive partner who made sure I didn’t so much as wash a single dish or do a load of laundry my entire pregnancy. He held my hair back when I puked, did counterpressure on my ribs and hips when I was in so much pain that I couldn’t breathe, took me to doctor’s appointments, came to every ultrasound, held me when I was sad, and listened to all my complaining. I was surrounded by family, I was financially stable, I had a psychologist, I had a pelvic floor therapist, I had an amazing team of doctors. I was fine. What I really needed to prepare for was postpartum depression and anxiety. 

There were some clues that I missed, though. I am not a crier. I’ve always said, “if I’m crying, something is wrong with me.” And I was crying a lot. I would sob in the shower before going into work because I was in so much pain, and I knew that I would be in even more by the time I got home. I’d cry when I experienced the intrusive thoughts because they were so disturbing and intense. Again though, I chalked this up to “normal” hormonal changes. The trope of the pregnant woman crying over dumb things is everywhere. Ultimately, my experience was so discounted and my focus was so forcefully directed to postpartum that I couldn’t even recognize my own misery because I was too busy bracing myself for how much worse it was about to get. 

Relatedly, the messaging around pregnancy took a toll on me. There are two conflicting lines of rhetoric. First, pregnancy and having a baby is the most joyous and wonderful time of one’s life. Second, if you think pregnancy is bad, just wait until postpartum… it gets so much worse. You never sleep, your relationship goes to shit (they call this the “roommate phase”), your career takes a huge hit, you will never feel like yourself again, your body is in shambles, you pee a little every time you laugh, your friendships fall apart, your dog won’t mean anything after experiencing love for your baby, and any hobbies you may have had before the baby are gone for at least a decade. Society did not have space for me to be myself and a mother. I was told that I would lose myself to motherhood and I would be happy about it, but this black and white dichotomy was so completely at odds with who I am as a person. My inability to rectify this message with my own understanding of myself caused me to feel unbelievably hopeless.

I felt no joy. I was not excited to have a baby by the time I was deep into the third trimester, I was simply excited to no longer be pregnant. Further, I felt like I had completely ruined my life for nothing. I was experiencing a deep, raw grief for my life. My pre-pregnancy life wasn’t perfect, but it was damn good. I had a vibrant, beautiful, healthy marriage that I loved–which I was told would be reduced to cinders. I was told once I had a kid I would no longer care about my career or research, something that brought me so much fulfillment and that I was passionate about. I had wonderful friendships and hobbies. I loved my body, I danced and walked and worked out and generally led a very active life. And my precious senior rescue was a bright spot in my world. All of which, I was told, would be stripped from my life, never to return. 

I will never forget a family holiday gathering where someone asked me how I was doing and I said “awful” to which they responded, “Really? Pregnancy is the fun part! Everything after is what sucks, but you forget and then you’ll want another one.” I wanted to grab them by the shoulders and scream at them “Look at me! I’m a shell of myself! I’ve ruined my life! I feel nothing, and I don’t want to live anymore! How could you say such a thing to me right now?” I didn’t feel like I could survive things getting worse, and I grieved as if I was mourning the loss of a dear friend–myself. I did not want to join the club of women who died on the altar of motherhood; waking up one morning decades later, to find themselves drifting aimlessly at sea, the only thing left of themselves being the remnants of a once magnificent ship now void of its purpose, crew, and beauty. I could not live with this prospect for my future.

I was desperate for a shred of hope that things could get better. So, I started looking everywhere. Funny enough, I didn’t find that hope in the academic literature, in my psychology department, at my doctor’s office, or with my family or friends. I found hope on Reddit, after reading story after story of women suffering horribly through pregnancies, thinking postpartum would quite literally kill them, only to be extremely pleasantly surprised when they felt immediate relief the day their baby was born. Not only that, but that pleasantness continued because the nausea was gone, the heartburn was gone, they could walk without bone pain, they could take full deep breaths, they could sleep, and most importantly, they felt more like themselves after the baby was born! Pregnancy was their rock bottom. 

The day my son was born will always be the best day of my life. Now that I’m on the other side, with a beautiful, perfect, healthy baby boy, I feel pretty certain that pregnancy was my rock bottom. Much like those women on Reddit, I felt better within hours of delivery. Even recovering from a cesarean section with an exclusively breastfed newborn baby, I felt so much more like myself. I spent my entire pregnancy preparing for every bad outcome, mourning the life I had loved, but I never once imagined life would actually be wonderful on the other side. I am happy and at peace. I am sleeping more and better now than I did during my entire pregnancy. Recovery from the c-section has been significantly less painful (and much easier) than the pain I experienced during pregnancy. Also, I’m no longer wrecked with worry and intrusive thoughts about my family’s well-being. I have my mojo back–I’ve been painting, spending time with friends and family, and enjoying life again. And I get to do all of this with my sweet son in tow. I love being his mom. This has been the upside surprise of the century for me. 

I share these rather personal details of my pregnancy because it was stories from strangers that gave me a little shred of hope when I felt like I couldn’t keep going. I also share my story because if I was having problems articulating and interpreting my experience—as a clinical psychology trainee—surely other people have and are struggling with this, too. We must change the messaging around pregnancy and peripartum depression to acknowledge the diversity of experiences–postpartum is not always worse and can be a great relief for some. People telling me that things “only get worse” and that I would simply forget and want more children when I told them I was feeling horrible nearly did me in. For me, things got much better after I had my baby. While I would be remiss not to acknowledge my privilege of having a supportive partner with parental leave and financial stability, that pesky “biggest hormone change in one’s life” that everyone is so afraid of was actually a godsend. 

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What can be done? How can we help pregnant women experiencing anxiety and depression in situations similar to my own? First and foremost, the way clinicians screen pregnant women for mental health challenges would benefit from a consideration of how patients interpret and misinterpret their experiences in the context of their expectations. A discussion about what depression and anxiety look like amidst a difficult pregnancy with many health challenges is also essential. Where normal ends and where abnormal begins is not always obvious, and often patients may be reluctant to acknowledge the severity of their distress, but a discussion that brings them out into the open can be a valuable opportunity for patients to reflect on their own interpretations. Further, counseling about options for medication should always be accompanied by information about the safety and efficacy of medications during pregnancy. Physicians should not wait for pregnant women to voice concerns about safety during pregnancy; it should be assumed that this will be a concern and should be preemptively addressed transparently with the relevant data. 

Second, we need more research on and better clinical tools for pregnant women experiencing mental health challenges. The field could greatly benefit from a more refined conceptualization of how internalizing symptoms may present in the context of pregnancy related changes and how to tease apart what is what. Third, healthcare providers and laypeople alike should work to center the pregnant woman in her experiences. That is, not viewing her as an incubator of new life, but as a separate person with an entirely separable experience. I am so grateful for the people who could understand that I was so excited for my baby and so very miserable. 

Perhaps the greatest lesson I learned from this experience is that just because an experience is understandable or expected does not mean it’s not disruptive, impairing, or debilitating and deserving of treatment. I wonder how many women have written off seeking extra support in the form of medication or psychological intervention because they believe that it is “normal” to be so impaired and disabled during pregnancy. My psychological symptoms were a consequence of my pregnancy and the challenges it presented, but this did not make them any less debilitating and horrible to live with. Unfortunately, part of the “oh, that’s normal!” messaging around pregnancy means that highly disruptive symptoms have no solution and women’s discomfort and pain are not viewed as problems that require fixing. Women’s health issues are not prioritized in medical or psychological research, in our doctor’s offices, or in our society, and because of this, we all suffer.

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