In the weeks after giving birth at Stanford Hospital, Laura Keller filled out periodic developmental forms about her newborn son at the pediatrician's office. Does your child lift the head? Does your child smile? Does your baby drink breast milk or formula?
At the end of each form was another question: Has mom been feeling sad, anxious, hopeless or depressed often?
She always answered "Yes."
No one followed up with her, Keller said, and she never asked for help. But behind her one-word answer was a quietly brewing storm of postpartum depression and anxiety that she battled mostly by herself for the first seven months of her son's life. She was perpetually exhausted, irritable, angry and anxious to the point of insomnia. When her son would finally sleep, her racing mind would keep her wide awake. She loved her son and husband but wasn't enjoying becoming a mother. She fantasized about running away from her family.
"I just wanted to leave everything behind," Keller said. "I felt like my family would be better off without me."
Postpartum depression is distinct from the "baby blues," or the normal mood swings, exhaustion and irritability that the vast majority of women experience in the first two to three weeks after giving birth.
Postpartum depression is caused by a dramatic drop in hormones compounded by sleep deprivation and other risk factors. Symptoms in the first year after giving birth include feeling intensely overwhelmed, irritated, angry or hopeless; a lack of appetite and insomnia, or eating and sleeping too much; difficulty bonding with the baby or having thoughts of hurting the baby; and suicidal thoughts, according to the National Institute of Mental Health. While a family history or pre-existing mental illness makes a woman more susceptible to postpartum mood disorders, there is no single cause, according to Postpartum Support International. For some women, postpartum depression can be their first and only experience with a mental illness.
Research shows that postpartum depression, if left untreated, can have serious consequences for both mother and child, including suicide risk, attachment difficulties and cognitive and language delays.
To say that Keller felt alone in these feelings would be an understatement. But the reality is that postpartum depression is the most common complication after pregnancy and affects one in five women, according to Postpartum Support International. Yet most women who experience it struggle in silence, whether due to a lack of awareness that treatment is available or because they fear that asking for help would be an admission they have failed as mothers during what is supposed to be the happiest time of their lives.
Even for those who are willing to seek help, it's hard to know where to turn. Specialized mental health treatment options for new mothers are few and far between, even in the Bay Area.
Keller, a 36-year-old Menlo Park resident who grew up in Palo Alto, is one of many local mothers who in the thick of her postpartum depression could not imagine talking about it openly with anyone. But they now see their experience as a call to action to push back against the stigma new mothers often feel.
"At some point I said to myself, 'This isn't going to define me,'" said Lisa Abramson, a Menlo Park mother of two who experienced postpartum psychosis, a rarer and more severe postpartum mood disorder. "I decided to share my story. So many people (said), 'This happened to so-and-so's sister or so-and-so's sister-in-law,' or 'My mom had something like that.' No one's talking about this."
Before having her first child, Keller suspected she might experience postpartum depression — but it didn't make it any easier to recognize or treat.
Keller grew up on the Stanford University campus and met her now-husband at Palo Alto High School. Depression ran in her family, though it wasn't talked about. She went through a "phase" in high school that she now recognizes as depression. She saw a school counselor and psychiatrist at the time but neither were helpful.
She worked for several years, then attended the Stanford University Graduate School of Business. In 2014, she became pregnant with Jackson.
The birth was challenging — he contracted jaundice and had to be readmitted to the hospital — and once they were home, Keller had difficulty breastfeeding, so he wasn't gaining weight. Keller and other mothers described the feelings of guilt and shame they faced in being unable to breastfeed, a common situation but one that goes against messages they heard repeatedly in hospitals and from health care professionals: "Breast is best" and formula is looked down upon. Coupled with sleep deprivation, breastfeeding challenges can be the catalyst for postpartum symptoms for many women.
Keller's husband got just five days off from work as paternity leave. When he returned to long hours at his real estate private equity job, she was alone with their screaming, sleepless baby.
"I was exhausted," Keller recalled.
A self-described type-A person, she also was resentful that her husband went back to work, but overwhelmed by the prospect of doing so herself. She didn't know how to tell her employer how she felt, so she quit her job. The drastic transition from one's "old life," including career, to first-time motherhood is for many women jarring, akin to an identity crisis, Keller and other mothers said.
Because of Keller's negative counseling experience in high school, she was reluctant to reach out for help. She, like many mothers who experience postpartum depression, worried that her baby could be taken away from her. None of her close friends had children yet and she didn't want to turn off women she had only recently met in mothers' groups by talking about the tornado of emotions that was raging in her head. So she kept it inside.
"I probably acted like I was fine, too," she said. "I kept telling myself, 'This is the new me. I'm never going to get better.'"
By chance, she discovered a treatment program: the Maternal Outreach Mood Services (MOMS) program at El Camino Hospital in Mountain View, which provides new and expecting mothers with therapy, targeted support and education. Keller was checking references for a nanny she hoped to hire so she could have time to look for a job. One of them was Lisa Abramson, who sang the praises of the program that had lifted her out of a terrifying period of postpartum psychosis.
Keller and other mothers describe the MOMS program as life-saving. Starting at four days a week, mothers attend group, individual and couples/family therapy at El Camino. Their partners and family members also participate — as does, most importantly, their baby. The hospital emphasizes that the success of the program depends on jointly treating mother and baby.
"You cannot forget the baby in the treatment of the mother," said psychiatrist Nirmaljit Dhami, the medical director of the MOMS program.
The program restored Keller's faith in the power of therapy. She learned how to identify negative thought patterns and focus on self-care. She recalled an impactful session on guilt and "shoulds."
"They tell you not to say 'should,'" Keller said, like "I have an MBA; I should be a corporate executive. I should be loving this baby thing. I should be able to keep my house clean."
But most healing was simply being in the presence of other mothers going through the same thing. Because the program admits patients on a rolling basis, there are women at every stage of recovery, from frazzled and defeated on day one to graduating and healthy.
"You get to see them improve," Keller said. "That was definitely a piece of hope. Maybe I can get better, too, because they're getting better."
After seven weeks, she left with a better understanding of her own mental health and the skills that would help prevent postpartum depression. When she had her second son, Noah, two years later, she could recognize her own warning signs and knew how to ask for help.
Though the experience was harrowing, it sparked in Keller a passion for mental health advocacy. Recognizing the opportunity that pediatricians have to help mothers catch symptoms early, she put together a detailed list of resources and gave it to her pediatrician at Palo Alto Medical Foundation's Palo Alto office, which now distributes it to all patients at the one-month newborn check-up.
For three hours every week, Keller is on the phone with new mothers calling into Postpartum Support International's "warm line," which offers help finding resources or, simply, an understanding ear.
Keller can't be sure if better mental health support as a teenager would have prevented her postpartum depression, but she knows it would have helped. As such, she's also working with Palo Alto youth mental health nonprofit Children's Health Council on a system to connect parents and teens with available therapists and on a separate project to increase counseling services for youth in East Palo Alto.
"I feel like my whole life could have been better if I had learned these coping techniques" as a teenager, she said. "I'm less scared of, what if I have another episode in the future? I feel like I know how to handle it now."
Lisa Abramson was having breakfast with her husband and mother when the idea occurred to her. She decided — rationally, she thought — to discuss it with her loved ones: Should she jump off of a bridge?
A month after giving birth to her first daughter in 2014, she was in the throes of postpartum psychosis, which occurs approximately after one to two out of every 1,000 deliveries and requires immediate treatment, according to Postpartum Support International. She had trouble breastfeeding, and with an exhaustive feeding schedule, she hadn't slept for three days. By that morning, she had lost touch with reality, she said.
She believed that she had been accused of a crime she didn't commit and that their home in San Francisco was being watched — spy cameras outside the bedroom window, snipers on the roof, police about to knock down the front door to arrest her. Her brain, she said, was on overdrive. She was afraid to be alone with her newborn daughter, Lucy.
"It was like I had stuck my finger in an electricity socket. There was no off; there was no down; there was no mellow," said Abramson, who had never experienced any kind of mental illness before. "At night I just sat there. My mind was buzzing, buzzing, buzzing and my heart was pounding."
Abramson, then 30 years old, had been a successful marketing executive and then a mindfulness coach who preached health and well-being. To ensure her daughter was fed and gaining weight, she sacrificed her own sleep, leading to the early stages of psychosis. At first, it manifested as confusion — like forgetting how to put together a breast pump she had used dozens of times and not understanding the nuance of a sarcastic joke — and then devolved into active paranoia.
"My confidence and my trust in myself just chipped away as I got on the third day of not sleeping. All of a sudden I said, 'Who am I without my mind?'"
After the breakfast-table conversation, Abramson's family brought her to the emergency room at a local hospital. She was admitted to the psychiatric ward and quickly placed on anti-psychotic medication, but the paranoia and confusion continued. She was unsure if she was in a hospital or a holding facility before a trial for the crime of which she had been wrongly accused.
When her husband, David, and mother visited the first few days, she was catatonic and not speaking, he said. Without any prior experience in the byzantine world of behavioral health, they became her relentless advocates.
"We were talking to her constantly, asking her questions, reminding her about what was really going on. We were constantly reinforcing, 'You're in a hospital. You're getting better,'" said David, who took two weeks off work to support her and take care of their newborn. "We were doing the job of bringing her back to reality more than the doctors."
Abramson was in the psychiatric ward for 10 days, but it wasn't until her husband printed a webpage explaining postpartum psychosis that anyone mentioned the condition to her. (A first-year resident assigned to her did not know what postpartum psychosis was, her husband said.) The combination of Abramson's mental state and the lack of information led her to believe he had invented a term to make her feel better.
The psychiatric ward was "grossly underprepared to care for a mom," Abramson said. "No one even acknowledged in my treatment at all that I was a mom even though that was what got me there. My husband bringing in that paper was the first time that I knew this has a name ... and it's related to having a baby."
While she was in the psychiatric ward, David was frantically researching her condition, looking for treatment alternatives and battling a medical bureaucracy that made visiting a locked facility with a newborn close to impossible.
"It's such an important stage in the bonding between mother and child," David said. "We really had to fight for it."
In brief visits with their daughter in makeshift meeting rooms and a small doctors' library, he saw glimmers of his strong, loving wife.
They also found the El Camino Hospital mothers' program, recommended by a therapist David found during his research. After Abramson was released from the psychiatric ward, she went to El Camino for a partial hospitalization before transitioning into the program. David also participated, including going to a support group for fathers, who can also experience postpartum mood disorders. They moved in with her parents in Menlo Park for the duration of the program and now live there.
El Camino's specialized program was "night and day" compared to the psychiatric ward, Abramson said.
"I could bring my daughter with me to the classes. I got my confidence back in being a mom. I was there, thankfully, in community with other moms, which I think is so important. I realized I wasn't alone, whereas (before) I thought I was the only person who had ever had this happen to me."
The program restored her sense of self as an individual and as a mother. Five years later, she tears up recalling video recordings the staff took of her interacting with Lucy.
"It was touchingly beautiful because I thought, here I was screwing up everything and they're like, 'No, look, you can tell when she's hungry. ... You're able to read her expressions.' My confidence was low, so they were able to show me that."
Shame and guilt go hand and hand with parenthood at any stage. But for a new mother with a mood disorder, it's even more heightened. There's a disorienting "disconnect," Abramson said, when one's internal reality doesn't match with the promised glow of motherhood — or the Instagram posts of brightly smiling moms who appear to have it all together.
Shame kept Abramson quiet at first — she planned to take her psychiatric-ward experience to the grave, fearful that it would derail her mindfulness career — but in the ensuing months she changed her mind.
A year-and-a-half after having Lucy, she wrote about her experience in a Medium post titled, "Why I Wanted to Jump: My Journey into Postpartum Psychosis and Back Again." Nervously, she shared it on her Facebook page. The response was overwhelmingly positive and led to her giving a TedX talk. She frequently hears from mothers who have watched it on YouTube at a dark time, thanking her for helping them feel less alone.
She also created a resources website called Wise Mama, based on a book she wrote when she was pregnant with her second daughter about the transition from career into motherhood.
Abramson ends her TedX talk with a sobering statistic: A mere 15 percent of mothers who experience postpartum depression receive professional treatment.
"I think we can do better," Abramson says in the video. "Too many moms are suffering in silence because of the shame and stigma associated with maternal mental health disorders. This is not a moms' issue. This is an everybody issue."
Rebecca Levin had always loved kids and wanted to have her own. A Palo Alto teacher, she prided herself on being good with children and felt prepared for the arrival of her first child, Benjamin.
But after she gave birth, everything shifted. She felt bowled over by the realities of taking care of a screaming baby with acid reflux, the difficulties of breastfeeding and the emotional toll it all took.
"I was just overwhelmed and felt like I was doing everything wrong," Levin said. "I thought I was going to be better at it and love it more at first."
Looking back, she believes she had postpartum anxiety, but she was never formally diagnosed.
Now the parent of two young children, she wishes that maternal mental health wasn't such a taboo topic, only acceptable in the context of a medical diagnosis.
"I was never formally diagnosed with postpartum depression, and I feel like there's a stigma about even saying that," Levin said. "I feel like it should almost be assumed, that it's almost a given, and that doctors should prepare and society in general should prepare to help people."
Levin, who grew up in San Francisco and lives in Mountain View, is a history teacher and guidance counselor at an international school in Palo Alto. She got married in 2012 and had her son two years later, then a daughter in 2017.
After Benjamin was born via cesarean section, the difficulty she had breastfeeding felt like a personal failure and required setting aside her own health and well-being. Like many mothers, she felt an intense pressure not resort to feeding him using a bottle.
"I should have given up holding myself to such high standards and said, 'It's OK if I just want him to be bottle-fed.' I was so determined not to fail at it," Levin said.
Her understanding about maternal mental health was limited to reading about the "baby blues" and the disturbing headlines about women who harmed themselves and their babies (though there is no direct correlation between infanticide, abuse or neglect and perinatal mood and anxiety disorders, Postpartum Support International says). She was reluctant to reach out for help because she didn't want to go on medication while she was trying to breastfeed, a common fear. She did tell her doctor that she was experiencing something that felt like postpartum depression and anxiety. Her doctor told her how important this was to address and asked her to make a follow-up appointment, which she ended up canceling because her baby was sick.
Looking back, she said she wished her call for help had been met with a sense of urgency on her doctor's part.
"I don't think there's enough in this country to take care of the mother. I was very aware of the fact that when I was pregnant everyone was asking me, 'How are you?' The second the baby was born it was all about the baby. What about me?" Levin said. "No one was really asking me how I was doing."
Levin sought support through local moms' groups, lactation consultants and the nonprofit Parents Place in Palo Alto. Six weeks after the C-section, she was cleared to exercise, which helped her feel like herself again, she said.
She was better prepared for her second child — more aware of what would trigger anxiety and stress, so she could head that off at the pass.
Levin wishes someone had told her before she became a mother that what she experienced is common, normal and temporary. She urges women to educate themselves on available resources before giving birth and to prepare for their own emotional triggers. She, for example, gets overwhelmed by a messy house, so they hired a house cleaner after she had her second child.
When Levin opens up to other mothers about what she went through, she typically encounters two kinds of responses. Some, relieved, divulge their own darkest moments. Others paint a blissful picture of life with a new baby.
She said she appreciates both responses, finding comfort in the shared commiseration and positive reminders of the joys of motherhood.
Turning the tide
Despite the persistent stigma surrounding maternal mood disorders, mental health professionals and other experts are hopeful that the tide is starting to turn.
Aarti Gupta, a Palo Alto clinical psychologist who works with new mothers, said she's seen a shift in awareness over the last decade. More women are willing to seek help and are coming in better informed about postpartum depression.
"I think there is starting to be a dialogue about postpartum depression," she said. "More women are coming out and saying, 'I'm not happy all the time. This seems different.'"
Katherine Williams, who leads Stanford Medicine's Women's Wellness Clinic, described the shift in awareness of maternal mental health over the last 25 years as an "explosion." When the clinic opened in 1994, there was not a widespread recognition of how to evaluate and treat postpartum mood disorders, Williams said.
Now, the clinic is busier than the staff can handle, working with new mothers as well as training psychiatry residents and educating OB-GYNs, primary-care physicians and pediatricians.
At Stanford, Williams is working to break down the longtime barriers between the psychiatry division and the departments that new mothers most frequently visit. A psychiatrist is now embedded inside the obstetrics and gynecology department — a new model for integrated health care that she hopes will be standard across the country in several years, she said. (They placed a psychiatry resident inside Stanford's pediatric center two years ago but women didn't come. Williams speculates it was due to fear of disclosing any mental health issues to their pediatrician.)
Training is also crucial; Williams serves on a task force developing a national curriculum for medical and psychology schools on the evaluation and treatment of perinatal disorders.
Stephanie Lai, Keller's Palo Alto Medical Foundation pediatrician, said she received little training in residency on how to detect signs of postpartum mood disorders and what to do if she did suspect a mother was struggling. Pediatric check-ups are brief, about 15 to 30 minutes, and focused on the baby's health, she said.
"It was only through experience and my patients did I realize that it often presents more subtly as parents who seem (more) anxious than usual, have many concerns about their baby or seem to have very poor sleep," Lai said. "These were often the most challenging visits because after answers parents' many, many questions about their baby it left little to no time in the visit to really check and see how the parents are actually doing -- which I now understand is probably the most important question."
California is starting to shore up the health care system to prevent struggling mothers from falling through the gaps. In September, Gov. Jerry Brown signed into law a package of bills related to maternal mental health. Together, the bills will require: obstetricians to screen mothers at least once during pregnancy or after giving birth; hospitals to provide maternal mental health training to clinical staff who work with new or expecting mothers and to educate women and families about the signs and symptoms of maternal mood disorders; and the Department of Public Health to apply for federal funding to support programs and a public-awareness campaign.
Public storytelling about maternal mental health — including by successful women like tennis player Serena Williams, model Chrissy Teigen and actress Alyssa Milano in recent years — helps "normalize" postpartum depression, Williams said.
"It gives people a sense of dignity," she said.
• Postpartum Support International: postpartum.net, call help line at 1-800-944-4773 or text 503-894-9453
• Santa Clara County 24-hour suicide hotline: 1-855-278-4204
• Crisis Text Line: Text "HOME" to 741741 for free 24/7 confidential support
• Supporting Mamas confidential text line: Text 408-475 4408 to speak with a trained volunteer from this Santa Clara County organization.
• El Camino Hospital Maternal Outreach Mood Services: Call 866-789-6089 or 650-988-8468 to schedule a free, confidential assessment.
• Women's Wellness Clinic at Stanford Medicine: med.stanford.edu/womensneuroscience/wellness_clinic.html or call 650-498-9111.
This week's "Behind the Headlines" webcast and podcast features MOMS program Medical Director Nirmaljit Dhami in conversation with reporter Elena Kadvany. Watch the show on our YouTube channel or listen to the discussion on our podcast page.