Staying well

I am pretty determined to do what I can to improve my life in Max's honour. Though life is infinitely darker without him, I want him to know that although his death brought darkness, his birth brought only light, and that I will do everything possible to keep that light illuminated through all the days I have left on this earth.

To begin with the biggest, most challenging improvements first, I am working with my psychiatrist in the hope of improving my resilience to anxiety and depression - those things that sucked the joy out of my pregnancy and threaten always to return - in the future. As I mentioned in a previous post, depression is a risky state to be in when you're pregnant, and the medications used to treat it are also still so misunderstood, each carrying an often conflicting collection of risk factors that no one has yet really managed to isolate or address in any meaningful way.

When I look to the future, just beyond the grey fog that is clouding my present, I see my wish for a baby, a younger sibling for Max, float up haltingly on the face of a lonely balloon. It's not a confident wish on a strong helium balloon, but one that's perhaps been lost along the way and is now just ambling along on the breeze in the background, making itself visible only when there's a small gap in those dark, grey clouds.

If there's even a glimmer of hope that I might one day be fortunate enough to find myself pregnant with another baby, I owe it to myself, to Max, and to that little being to do my very best to enjoy, not endure, the miracle of pregnancy. In order to hope that things might be different in the future, I need to do some hard work right now. Though it remains fairly likely that I would have to continue the medication I now have so many doubts about, there are some other things that remain firmly in my control that I can alter and improve. If these alone cured my depression that would be an amazing result, but even if they lessen its impact or duration, or do absolutely nothing at all, I have nothing to lose and everything, potentially, to gain.

I've worked with psychologists for well over a decade now with the gritty, messy, emotional side of mental illness - its origins, its triggers, its impacts. I can say with some confidence that I'm a very self-aware, reflective person as a result of all of this mind work, and that I definitely live a deeper, more rewarding life because of it. Still, though, after a lifetime of therapy, my depression recurs. I've built a thousand different weapons to fight it, but sometimes the ongoing battle to stave it off is more exhausting  than the enemy itself. As strategies in a war, the avoidance and re-framing techniques I've learned through cognitive behaviour therapy don't do much to relieve the tensions. Rather, they prolong the state of war until you're so run down you have no other option than to surrender.

It's taken me a long time to come to terms with the fact that any therapy or mind work I've done has not cured my depression. It has never gone away, although it has given me relatively long periods of reprieve at times. I'm tired of the fight, and scared of the impact of its repeated negative outcome, so I'm changing tactics. I'm not going to try and eliminate the enemy but rather to accept it as an ever-present foe and get on with my life nonetheless. Looking forward, I will be working on a combination of mindfulness practice, which I am very familiar with already, and Acceptance and Commitment Therapy (or ACT) as a way to better live with the demons on deck of my ship and stop wasting my energy trying to push the bastards overboard. For those interested in ACT, Dr Russ Harris's book The Happiness Trap is a fantastic resource that explains it in layman's terms. I have read it innumerable times and always it has re-grounded me and reminded me that expecting life to be happy and free of suffering is an unrealistic fairytale.

For the first time ever, I now also have a list of practical ways I can better support and nurture my mind and body that don't involve simply talking about my feelings - not even once! This coming week is the first where I will try wholeheartedly to implement them all to the best of my ability. It is, I know, going to be a tough and tiring week. Here is a brief description of what my new 'wellness' plan entails:

• Mindfulness meditation each and every day. This practice aims to strengthen the brain's neo-cortex, the part that's responsible for reasoning, and which does not operate as effectively as it should in depressed people. Daily practice of these meditation principles teaches you to be more aware of which parts of your brain are in control and whether you should pay any attention to the stories each part will inevitably tell you throughout the day.

• Vitamin supplements. There are a couple of vitamins that have been identified as being complicit in making nerves and brains work correctly, and whose deficiency have been linked to some kinds of mental illness. These are: B Vitamins, Vitamin D and Omega 3 fatty acids. 
• B Vitamins: I have pernicious anaemia, which means that I cannot properly absorb Vitamin B12, so I'm already at a distinct disadvantage in this area. This condition is in itself associated with higher rates of depression. B complex vitamins are needed to manufacture serotonin, melatonin and dopamine - all the feel-good chemicals that are needed to regulate our moods and cycles. B vitamins are destroyed by things like refined sugars, which make up so much of our modern diets, so it's really easy to become deficient in them. 
• Vitamin D is also something that I am deficient in. You probably are too. The slip, slop, slap campaigns have been so effective that no one wants to go outside anymore, despite the fact that we know that like plants, we need sunshine to grow and thrive. Vitamin D deficiency has been linked to a variety of serious health conditions, including multiple sclerosis, as well as depression.
• Omega 3 fatty acids are essential for normal brain development and there is increasing evidence that it can improve the symptoms of depression and bipolar disorder.

• Time outdoors - at least an hour a day. This is important not just because it aids the production of Vitamin D in our bodies, but because we need daylight to set our biological rhythms. There's also the added benefit that if you're outside you're more often than not walking or being active, which brings me to my next point...

• Exercise - at least 30 minutes a day. Swimming is good as it's rather meditative in itself, but walking is good too. This, along with good nutrition, are obvious contenders as medal winners in the wellness battle. Both reduce the work your body has to do to keep you functioning. As I found out when I was pregnant and suffering for months with hyperemesis, being physically run down has a significant impact on the way you feel.

All of these, I know, sound just like common sense - things that everyone should do as a matter of course. But I've never had a reason before for making these small things count, and for measuring the changes they might bring in a real and tangible way.

This week it is my homework to figure out how I can practically incorporate each of them into my life on an ongoing basis - how I can make sure I get the exercise even when I don't feel like it; how to take time for the meditation no matter how busy I am. This is going to be the hard part, as so much is hard when you change your routine. We're creatures of habit and habits are hard to break. But they're not as hard to break as babies are to lose. I will do everything I can, no matter how small or seemingly inconsequential, to stay well for my baby Max and to show him how much he has changed my life in the most positive and meaningful of ways. 

Passing the final test

I was in the spectacular Manchester Unity building in the city today searching out an old-fashioned goldsmith when I received a phone call from my obstetrician who had the results of my final round of pathology tests. She delivered good news - testing for a variety of blood clotting disorders that may have contributed to my preterm labour came back clear. Now I know with certainty that there is no underlying medical problem to explain why this happened. I know that have no physical abnormalities (like a weakened cervix) that can be diagnosed or treated. My baby had no known 'defects' or chromosomal abnormalities that might have caused my body to reject him. Whilst there was some evidence of a higher than normal number of white blood cells in my placenta, there was no identifiable infection or bacterial agent found to take the blame. It's looking more like those infection-fighting cells migrated to the placenta as a result of labour starting, not the other way around, leaving me with much less certainty than I thought I had a few weeks ago when I clung to evidence of an infection as a potential cause I could live with.

Instead, I've had to face the extremely painful possibility that Max's premature birth was a result of a medication I take for depression and generalised anxiety disorder. This fear has been in the back of my mind for a long time now, and though there is no way of knowing for sure if it had an impact, the possibility remains a real one. The medication I take is in Pregnancy Category C, which means that animal studies have shown adverse effects, but that there are no adequate or well-controlled studies in humans. Nine months before I got pregnant I consulted a specialist psychiatrist to get advice about what it would mean for me to have a baby given my long history of depression and the fact that I have relapsed every time I've tried to go off medication in the past. After detailed consultation, and in conjunction with my GP, she advised that it was best for me to remain on medication throughout a pregnancy despite the potential risks. I felt that this was the right decision. Whilst the medication has side effects, untreated perinatal depression is also not a risk-free state, either for mother or baby.

Ironically, both SSRI's (the type of medication I take) and untreated depression during pregnancy have been associated with an increased risk of preterm birth. In the literature scientists do have about my medication, this chance is still very slight, though. There are thousands of women who take this medication and suffer no adverse affects. My psychiatrist has 25 years experience treating women like me during their childbearing years and this has not happened to any of her other patients. If the medication was a factor, I was the unlucky winner of a very unfortunate lottery, in other words. She has reported my outcome to the manufacturers of the drug and my experience will go towards compiling the kind of statistics that I had to weigh up during that first prenatal appointment.

I saw Melanie every single week during my pregnancy. I did not have an easy time of it. Despite remaining on medication, I became extremely depressed. Hyperemesis (the severe kind of morning sickness I was plagued with) is known for contributing to depression in pregnant women, even those who don't have a history of it. It seemed that I was also particularly sensitive to the progesterone saturation pregnancy causes, which has a big impact on the part of the brain that controls mood. There were quite a few months there when I did not know how I would get through another day. I was almost hospitalised at one point, and the strain that this put on my life, my work, and my relationship was a very real one. The week Max was born was really only the first or second of the entire pregnancy that I had begun to feel like myself again. I had hope that the worst was over and that I might finally get to a point I could enjoy.

During this time, depression meant that I could not be alone for any length of time. I spent days aimlessly driving around looking for things that 'snap' me out of it. So many times I sat in my car on the side of the road simply sobbing because I did not know where to go or what to do to escape myself. My house became a horrible symbol of all I felt inside. We moved in here just after I found out I was pregnant, and all it was associated with for me was sickness and misery. I didn't feel at home in my house, and I didn't feel like I belonged anywhere else. No wonder my car felt like the only space I could tolerate. Being depressed meant that I could not go to work; that I could not do anything useful or practical. I could not pick up a book. I could not stand to watch TV. I can't count the number of hours I sat just staring at the wall. Being depressed meant me thinking that I had made a terrible mistake in getting pregnant. I was sure that I was not capable of loving my baby. I imagined looking at him when he was born as if he was nothing to me. I was numb in every possible way.

Writing this, I remember how much I was suffering during those months. Now that I'm not pregnant anymore, and I so desperately wish that I still were, I find myself unable to reflect very truthfully on what it was like. I romanticise what it was like, and in doing so I punish myself. From where I stand now it feels like it could not have been all that bad. Maybe I was making it up. Maybe I was just feeling sorry for myself and wanted attention. Surely if I really loved and wanted my baby I would have just gotten over it.

It's cruel of me to taunt myself with what I know to be impossible recriminations. In my lucid moments I know, more than anyone, that depression is a very real, very frightening, very serious illness that cannot be wished away or recovered from with sheer force of intention and will. But still I say to myself, with so much self-hate, that I should have been the exception. That I should have tried harder. That I know better, and could have done better, and shouldn't have let myself get in that dreadful state in the first place. If I was a diabetic instead of a depressive would I feel that I 'made up' or imagined my pancreatic failings? Probably not. Why it's then so hard to believe in the very real failings of my brain I don't know. If someone could show me on an x-ray exactly where my neurons were misfiring and where my brain's chemical markers were going awry perhaps I'd give myself a break. Until then, I'm plagued by a misconception that instead feels like a truth - that depression is a choice, and that in choosing it I was also responsible for my baby's death.

I don't know how to live with this uncertainty, with this guilt. I trust, implicitly, the advice of my psychiatrist and all those she consulted about my case. I trust her research and her skills and her experience, but no matter how much she tried to assuage my feelings I cannot seem to find that same sense of reassurance in myself and my own actions.

This is something that is not going to go away. If we try again to have a baby I'm going to be faced with this exact same situation and the exact same set of 'choices' that aren't really choices but instead a never-ending mathematical weighing up of risk against risk. It's enough to make you go mad if you weren't already.

Today I just feel so sorry. I feel sorry that no one can give me any better answers or more certainty. I feel sorry for everyone around me who helplessly watches me fade away into a place that distorts my thoughts and feelings and leaves them with only a shadow of the person they know and love. I feel sorry that something in me is broken and so sorry that I do not have the power to fix it. I am sorry to my little boy for any part I may have played in his demise and I absolutely beg for his forgiveness. I love him and I long for him. I long for him so very much.