Editor’s Note: *The name of our subject has been changed to protect her privacy.
Over the past year, the pandemic’s stay-at-home orders and mandatory lockdowns have kept plenty of people around the world shut inside.
For Raquel*, hibernating at home has been part of her routine for almost a decade.
In 2013, the Chicago native was diagnosed with agoraphobia, an anxiety disorder with symptoms that include a fear of places or leaving one’s home, essentially due to embarrassment or panic. Even everyday routines, like taking public transportation or riding in a car, at times triggered panic attacks for Raquel.
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“It really, really affected my behavior at the end of college and after, where I tended to avoid all social interactions,” Raquel said. “I basically was home and then at work, and then home again. The things that I would gear up to do would be going to Target or going to Starbucks. I really, really, really limited my world.”
Post-graduation, Raquel was able to find a job that she loved and eventually got married, but it was another major life marker that finally forced her to deal with her mental health struggles: the birth of her daughter in April 2020.
“I couldn't really find the motivation to find solutions just for myself because honestly, I was like, ‘If I'm home all the time with my pets, that's okay,’ but I almost had to imagine this future child to motivate me to find solutions,” Raquel said. “So imagining the future that I wanted for myself and for my family sort of helped me to seek those different avenues, and that ended up being therapy and medication and just pushing myself to really try new things.”
The decision to start a family is always very personal and multi-faceted, but it becomes even more complex for those who have a history of mental health illness. The concerns can range from how the illness may affect the child, to whether medications can continue during pregnancy, to whether the condition is genetic and can be passed down.
“I always wanted to be a mom, but I think that there were periods where it just felt like it would be easier to not go that direction because I wouldn't have to push myself to make the changes that absolutely were necessary but that were hard to make, like challenging myself to go to new places and break some of the bad habits that weren't serving me,” Raquel said.
“So it was more a thought of, ‘Well, if I just avoid taking on the challenge of motherhood altogether, I won't have to face these hard realities,’ but I always knew that I wanted to [be a mom], so I had to keep that in mind, and I had to sort of find that motivation to find help.”
When Raquel and her husband started seriously discussing starting a family, she decided to go off of the medication she was taking to help manage her agoraphobia, in part because she thought that it would be harmful to a potential pregnancy.
“I made that decision initially because I thought that I had to… in order to have a healthy pregnancy, and I learned afterward that that wasn't the case,” Raquel said. “So I would definitely recommend that anyone who's asking themselves about how to navigate medication and pregnancy, I would recommend that they talk to their doctor because I think I had misinformation and I just didn't seek out the answers.”
Helping expectant mothers manage existing mental health treatment is part of what is offered at programs like The Motherhood Center in New York City, which specializes in treating pregnant and postpartum women who are experiencing mental health difficulties. Instead of new parents being forced into a high-stakes guessing game like – Should I stop my own treatment for a mental health disorder in order to protect my future child? – they can instead lean on expert advice. That extra information can lead to safer, healthier outcomes for all.
“Our reproductive psychiatrists are able to say, ‘Okay, look at the menu of medications that you're on,’ and say, ‘This is proven to be very safe to continue during pregnancy, this medication not so much, perhaps we can replace it with this,’ depending on the symptom acuity and the diagnosis of the woman that's receiving the consultation,” said Paige Bellenbaum, a licensed master social worker and founding director of The Motherhood Center.
For some couples, a worry of “passing along” their mental health issues to a future child can cause them to stop family planning altogether. This is another area where finding expert advice is better than making decisions based on fear.
In 2013, the Cross-Disorder Group of the Psychiatric Genomic Consortium conducted a study that found that the five major mental disorders – autism, attention-deficit/hyperactivity disorder (ADHD), bipolar disorder, major depressive disorder and schizophrenia – “share some common genetic risk factors.” A separate 2014 meta-analysis of 33 studies published in Schizophrenia Bulletin “found that offspring of parents with schizophrenia, bipolar disorder or major depressive disorder had a one in three chance of developing one of those illnesses by adulthood — more than twice the risk for the control group offspring of parents without severe mental illness.”
Of course, it’s not all hereditary. Environmental factors come into play, too. Concerns around how different daily stressors (like issues regarding work-life balance or problems in a marriage) might act as triggers or play a role in various learned behaviors associated with mental health disorders can be a real concern for expectant parents or couples starting families through adoption.
While Raquel says she doesn’t know for sure if her condition was inherited, she did notice a pattern of similar behavior from other women in her family as she was growing up. And she has also seen stress play a role in making her symptoms worse.
“I don't know if it's something that is necessarily genetic, but I just know that I witnessed a lot of behavior that I think became learned for me over time – like, I sort of learned to be fearful of certain situations,” Raquel said, “but it wasn't until senior year [of college] when I was imagining going out into the world and taking on the next challenge that I think it really boiled up for me.”
“The current understanding of a lot of mental health is that there's some genetic predisposition but that there's a lot of environmental triggers,” said Dr. Hannah Roseberry, an Atlanta-based OB-GYN. “If someone does come in, and they're like, ‘I’m really concerned about this being a risk factor for my future child,’ we obviously want to focus on [that].”
Another concern for potential new moms, particularly those with existing mental health illnesses, are perinatal mood and anxiety disorders (PMADS).
Pregnancy can prompt a variety of PMADS – including postpartum depression, OCD, PTSD, bipolar disorder and psychosis – and Bellenbaum noted that those with a history of mental illness, whether through their family or own personal struggles, are “at greater risk of developing a PMAD.” But no matter the preexisting mental conditions, there’s no precise way of predicting exactly how a pregnancy will affect a mother-to-be.
“That's the sneaky thing about PMADS is that even though women that do have a history of mental illness are at a greater risk of developing a PMAD, it doesn't necessarily mean that they're going to have one or experience one,” Bellenbaum said. She noted that she herself has a history of anxiety and depression and had severe postpartum depression and anxiety after the birth of her first child, yet was asymptomatic after the birth of her second child. “You can't just say, you know, ‘A plus B equals C.’”
Unfortunately, these issues often don’t receive much attention. While disorders like depression and anxiety are talked about openly and publicly now more than ever before, there is oftentimes a real stigma surrounding motherhood and honest conversations regarding mental health. It was something Raquel noticed during her pregnancy, especially in group settings with other expectant mothers.
“There was kind of a shyness to talk about it, especially about mental health, because you have this notion that as a mom, you need to have it all together, you need to have a plan, you need to feel confident and excited, and to feel scared or nervous or anxious is somehow bad,” Raquel said. “So I think that even among trusted moms-to-be, it was difficult to have open conversations about what we were experiencing.”
“Honestly, I feel like there's just such a stigma about anything other than just pure joy and happiness about being a mother, and I even see it in OB-GYN offices, and it's actually one of the ways that I sort of tailored my search [when] looking for a practice,” Dr. Roseberry said. “When I go in an office and all I see on the walls are just pictures of happy pregnant moms or moms with babies and these very artificial poses, I worry that that practice is sort of not going to be as focused on mental health and not prioritizing anyone's experience other than what is absolutely ‘pure joy is motherhood.’”
“We've already set the stage for this perfection, and we've already set the stage for all of these myths of motherhood, so when a woman finally does become a mother and experiences what so many either pregnant or postpartum women do – anxiety, depression, you name it, these symptoms are synonymous with new motherhood – then there's such a stigma,” Bellenbaum said. “There's so much shame and guilt associated with feeling these things, having these thoughts, the ambivalence of motherhood, that so many women suffer and struggle silently because they think they're the only one that it's happening to.”
Bellenbaum thinks that normalizing “the messy parts of motherhood” by simply being more willing to have open and honest conversations about the mental health aspects of pregnancy would be a major step in helping address the issue as a whole.
“It's so important for us to start to shift the conversation and make room for what we refer to as a ‘both and.’ Yes, you can look at your baby and think, ‘Oh, they're so adorable,’ and five minutes later feel like, ‘I think I made the biggest mistake of my life by having a baby,’” she said.
“You can be holding your baby, feeding your baby thinking, ‘I really love this moment,’ and five minutes later be thinking, ‘I hate breastfeeding. I don't want to do this anymore. This is so hard. I want to quit, but I'm afraid of what people are going to think.’ That is motherhood in its essence. It's a ‘both and.’”
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Having these conversations is the first step to normalizing mental health struggles surrounding motherhood, and that communication is a crucial part of the planning process for couples. When it comes to mental health concerns, for those couples with doubts in the early planning stages of starting a family, there are still plenty of options for information – like seeking out gene therapy or speaking with licensed professionals such as a reproductive psychiatrist or genetics counselor.
“Speak with some people who specialize in mental health and how it may or may not translate into having a child and having your own children,” Bellenbaum said. “Make sure that whatever decision you make is rooted in facts and not necessarily just feelings and fear.”
For those who have already started families, maintaining a healthy and truthful mental mindset is also key.
“I think that it's important to be honest and communicative about your struggles with your partner, with your family [and] with yourself,” Raquel said. “I think it's important to seek out help and to be open to different avenues – whether that be medication or therapy, or yoga, [or] mindfulness.”
For Raquel, she says managing her mental health struggles will always be a challenge, but seeing the world through her daughter’s eyes has helped.
“I really have to actively prioritize pushing past the panic or the fear or the anxiety,” she said. “I have to actively focus on that in order to have a successful, fun experience with the family, and it's definitely worth it because I don't want to exhibit the behaviors that I saw from my grandma and from a few other family members, as well, if that's the way that [my agoraphobia] could possibly transfer to [my daughter].”
While the pandemic has limited her opportunities to really venture out to new places, something as simple as a recent trip to a museum with her family marked a big step in her mental health journey.
“When we got down there and we got her in the stroller and we got outside, I literally said to my husband, ‘I'm a mom now,’ because it was one of the first opportunities we had to be out,” Raquel said, “and I was having this feeling of pushing the stroller downtown and on our way to go learn something and do this fun activity, and it just felt like something was coming around full circle.”
“Those of us who struggle with anxiety and or depression or another diagnosis – it doesn't define us,” Bellenbaum said. “It doesn't mean that we are anxiety all the time or we are depression all the time; it means it's something that happens to us, that we're able to treat it and intervene if we feel like we're symptomatic, and in the small chance that our child finds themself in a similar position, it's not going to define them, either.”
“I would hope that anyone who wants to have a child and be a parent wouldn't let their mental health concerns hold them back,” Raquel said, “because if you have that communication and you have the treatment and you are willing to love a child and push yourself and really grow, I think that it is extremely rewarding and also very possible to see change within yourself.”