That word, and the process that accompanies it, can bring about immediate stress for women suffering perinatal mood disorders. It's a highly charged issue. For some of us, difficulties in being able to do it at all send us into a tailspin, and can either cause or exacerbate postpartum depression and anxiety. I thought, if breastfeeding is one of the few things a female body was meant for, why the hell can't I do it? What a defective mother I was!! For others, breastfeeding is one of the only ways suffering moms feel connected to their babies, and the idea of taking medication is terribly distressing. They'd rather continue to be ill than take meds and have to stop breastfeeding, and are nervous about the risks of continuing and passing trace amounts of meds in their milk to their babies. No matter how we try to look at it, we are filled with dread, guilt and indecision. I've been meaning to write about this topic for a long time, but then I received an essay in my email this week from Lisa Sniderman. It is very poignant, and I've decided it will be more powerful to share her confrontation of this issue than mine, with her permission, of course:

My name is Lisa, and I have a 2-year-old daughter. Unlike some mothers, PPD was far from my first experience with mental illness. I have been diagnosed with bipolar disorder since age 22, although that diagnosis took 4 years of frequent hospitalization and medical guesswork. I have a "treatment-resistant" illness; most medications simply increase my symptoms. In 1993, I finally found my miracle in a combination of doxepin and lithium. I got on with my life goals, thanked my lucky stars and never looked back — until 2005, when I was newly married and hoping to start a family.

It turns out that while my medications could be titrated during pregnancy, because of my history I really, really needed them in full dose immediately after delivery. Just when my daughter would really, really need to breastfeed. Thus commenced a frantic search for safety information about the drugs.

The outlook couldn't have been worse. Doxepin had been shown to cause respiratory distress in nursing infants whose mothers took one-third to one-eighth of the dose I needed. Meanwhile, the lactation and neonatal experts were divided on lithium; some recommended 'extreme caution' and frequent neonatal bloodwork, while others said it was completely contraindicated. Call me nuts, but I couldn't really see myself, in my vulnerable postpartum state, carefully monitoring my newborn for apnea and hepatoxicity 24/7. I don't think I ever would have slept.

As it was, I panicked right after delivery and tried to go without my meds for my baby's sake. I lasted three days before uncontrollable suicidal ideations and racing thoughts sent me to the hospital. At that point, I realized just how real my illness was, though it had been dormant for over a decade. I went back on doxepin and lithium, and added an antipsychotic for the short term. At the time, I thought I was a terrible mother for needing these medications. Worse — I thought I was a terrible mother for having the illness that these medications treated (hello, stigma!). Was bottle-feeding really a 'choice' for me? Only if I could somehow have 'chosen' instead to spend my daughter's first year either in unbearable torment or dead. The rhetoric of personal responsibility that surrounds breastfeeding, despite the very real barriers so many women still face, disturbs me in general. When it is applied to severely mentally ill mothers who need uninterrupted sleep, mood stabilizers and antipsychotics, it absolutely stops me cold.
With the passage of time, I stopped cursing God for making me one of the few women who truly cannot breastfeed. I tend to search for the larger meaning in things, and I don't think it's an accident that the two medications I need are among the only psychotropic medications unsafe for nursing. I believe this happened so that I could critically re-evaluate my identity as a mother — and begin educating myself on the cultural disease of maternal self-negation that enrobes new motherhood in impossible expectations.
I gave my daughter a mother without a breast, because I couldn't give her a breast without a mother. I know that she and I missed out on a precious experience, but we humans are extremely adaptable and many other equally precious experiences came out of my recovery from PPD, and her subsequent development into a secure and happy little girl. I learned that self-acceptance radiates out, from me to my daughter. I learned that the real joy of mothering only comes from mothering oneself first. My husband and I are trying for our second child, a decision I made only when I felt fully reconciled to the idea of not breastfeeding this one, either. The stakes are just too great. The risks of bottlefeeding are well-known; the risks of untreated maternal depression, though they can be equally or more grave, are far less imprinted on the public consciousness. I accept this; the fact that I am knowledgable about my own situation is enough for me.
The ironic thing to me is that someone seeing me mixing formula at the mall might think to herself, 'What a bad mother. She must not care about breastfeeding.' When, in fact, I am a breastfeeding advocate and would staunchly defend anyone who took flak for nursing a baby — or a pre-schooler — in public. My story is not a threat to everything we know about the wonders of breastmilk, and I'm not presenting it as such. It is because breastfeeding is so important that my decision was so difficult. The interaction between PPD and breastfeeding can be a lot more complex than 'take Zoloft — it's safe!!' There are other women, caught in the distorted thinking so common in PPD, who refuse any medication out of fear of harming their nursing babies; weaning is sometimes necessary if it is the only way a desperately ill woman will accept treatment. Many OB/GYNs, lactation consultants and psychiatrists have little appreciation for these complex issues.
I am sharing this in the hope that some other mom out there reads my story and knows that if it comes to the point of treatment vs. breastfeeding, which thankfully isn't often the case, she can find the courage to be a mother without a breast, rather than no mother at all."
Take Lisa's words to heart. Your child needs a healthy mother. Some of you will be able to alleviate perinatal mood disorder symptoms with psychotherapy alone. Others will continue to breastfeed while on medication, because you and your doctor decide the risks for your particular medication are relatively low based on research. Still others will stop, because it is easier for them or because certain medications prohibit breastfeeding. It doesn't matter. Your child needs you more than anything.