Postnatal depression is much better understood today. Not so its darker sister, postnatal psychosis.
Gabrielle and Andrew Micallef had fallen for each other before they even met. Introduced on an online dating site, they got to know each other through an exchange of long, meandering emails. She was a psychologist in Wollongong, NSW, he a materials engineer in Hastings, Victoria. By the time they arranged their first date, a stroll along North Beach not far from Gabrielle's home, it was almost a foregone conclusion that they'd be together.
"I was so sold on his emails," says Gabrielle, "the way he communicated his thoughts and feelings. I could sense his energy."
Over the next few months, as their long-distance courtship moved inevitably towards a marriage proposal on the last day of 2011, they discovered that Gabrielle's talent for listening complemented his talkativeness, her softness rounded his angularity and her enthusiasm melted his circumspection, particularly on the subject of babies. As the fifth of seven children, she had always known she wanted a brood of them. Andrew, the youngest of four and still only 27, was less sure.
As it turned out, her timing couldn't have been better. Andrew's two older sisters, to whom he's close, were just starting to have kids. "I'd go with him to family gatherings and be, like, 'See? You're awesome at this'," she says.
Shortly after their wedding in November 2012 – "The best day of my life, probably" – they took off on a "last hurrah", eight-week trekking honeymoon in South America. Their happiness was crowned in the early hours of September 18, 2013, by the hasty arrival of David at Frankston Hospital.
Gabrielle, 32, is talking to me in the lounge of her large, white-clapboard house in Gwynneville, a suburb of Wollongong. She is tall and barefoot, a smiling, wavy-haired brunette in white trousers and a flowery top. Her pregnancy, she tells me, couldn't have been more textbook: she radiated that enviable, expectant glow, exercised right up to the end and barely made it to the hospital in time. One suck of gas and David, all 3.8 kilograms of him, was out.
Then he started crying – and just wouldn't stop, except to feed, which felt like all the time. "The first night we had him at home on our own, Andrew said to me, 'Gab, what have we done?' " she tells me. "We were exhausted. I think that lack of sleep was my undoing."
It started benignly enough. Gabrielle found that, despite being worn out, she was unable to fall asleep during those short periods in the day when David did nap. She had to keep checking up on him to make sure he was alright, that he was breathing. But no matter how many times she looked in on him, she couldn't quieten her brain or the anxiety that was starting to whirl around like a carnival motorcycle-rider inside a Globe of Death.
When David was four weeks old, Gabrielle's mother, Frances, a family case worker from Sydney's Quakers Hill who'd been staying with them in Mornington, Victoria, for two weeks, returned home. "There was a very significant sense of, 'How am I going to cope now?' " Gabrielle tells me. "I got really emotional, which isn't like me at all."
A few days later, she went to see her GP, who prescribed antidepressants. Gabrielle, who won't take Panadol for a headache, didn't want them. Instead, she made an appointment to see a psychologist. She made it to just one session.
She had become consumed by a new and troubling narrative, one that quickly established itself as her incontrovertible reality: she wasn't coping, she was a bad mother and David was going to be taken away from her. Worse, Andrew was conspiring with this nameless enemy to bring about her downfall.
"I wouldn't have anything more to do with him," says Gabrielle. "We had a clock on our living-room wall and I became convinced there was a camera in it. I was under surveillance and Andrew was reporting back to them."
She was ambushed by terrifying hallucinations. Standing naked in front of a mirror after a shower that took every atom of her rapidly dwindling mental and physical reserves, she saw that one half of her body was grotesquely scarred and disfigured. There were vivid flashes of arterial red, repeated visual cues of imminent physical annihilation. And she'd started seeing the face of her father, who died when she was nine, in the place of her baby's.
Gabrielle lapsed into a near-catatonic stupor, unable to act, eat or speak – "Because I was so scared of what I'd say" – and could no longer bear to have David anywhere near her, not even to hold him to her breast. "He was feeding all the time," she says. "I felt suffocated by him."
Desolately surveying the wreckage of his new family, Andrew wondered where on earth his vivacious young bride had gone. On the advice of their GP, he called the 24-hour Crisis and Assessment Team (or CATT, a kind of psychiatric SWAT team) to arrange a visit. With trembling fingers, Gabrielle managed to send a two-word text to Frances: "Come back."
PANDA (Perinatal Anxiety and Depression Australia) was founded in 1983 to raise awareness and reduce the stigma of postpartum mental illness. Until recently, says CEO Terri Smith, the organisation was reluctant to go public about the psychiatric emergency that is postnatal psychosis (PP) for fear of its being sensationalised. But it has recently begun working with "community champions", women who've survived it and want to talk about what's happened to them.
"They said, 'Come on, why aren't you doing anything about this? Every expectant woman and her partner should know that this is a possibility. It shouldn't be a secret,' " says Smith. "As a consumer-led organisation, we knew we had to represent their voices."
PP affects two women in 1000 in the days or weeks after having a baby. It's not to be confused with either the "baby blues", or postnatal depression (PND). More than half of new mums experience the first of these. It usually kicks in around day three or four, causing them to feel low, teary and irritable. It doesn't require any treatment and has usually cleared off by about day 10. PND is more serious. It has a minimum duration of weeks, and looks and feels like the kind of depression that can show up at any other time of life. It affects 10 to 15 per cent of women and is usually treated with a combination of therapy and antidepressants.
PP is their hulking, black-clad relative at the celebration, the uninvited guest who always leaves a trail of devastation, even tragedy, in its wake. It can strike without warning, swiftly spiral into debilitating mental illness and be dangerously unpredictable, capable of changing course from hour to hour. Its party pack comprises manic highs (the "baby pinks"), depressive lows, paranoia, delusions and hallucinations.
To make matters worse, the sufferer is often unaware she's descending into madness, so authentic has her substitute reality become. It falls to those who love her to sound the alarm – and sound it they must.
Professor Marie-Paule Austin is director of acting perinatal psychiatry at the Royal Hospital for Women (RHW) in Sydney and St John of God chair of perinatal mental health at the University of NSW. Her windowless office, accessed by way of a labyrinthine, ground-floor corridor at the RHW, contains two desks with a computer on each: one for research, the other for her clinical work. She listens intently and talks slowly in a low, well-modulated voice, the signs of someone who spends her days in the company of the emotionally ravaged.
"Women suffering from puerperal psychosis don't come forward themselves typically," she affirms. "They lose what we call 'insight', the ability to distinguish between what's real and imagined. Often families are loath to seek help when the mother becomes unwell: they don't want her to feel that they don't trust her with the baby. She might see any efforts by family to help as proof that they wish to harm her or take her baby away." Often, a well-meaning husband finds himself at the centre of his wife's paranoid delusion.
"But if the psychotic episode is more depressive," continues Austin, "a mother might start to think that the world is too bad a place for her and her baby to live in. And thoughts like these can lead to very dangerous outcomes."
Asta* is a 29-year-old nurse who lives in rural South Australia. As we talk for almost an hour over Skype, she asks me not to publish her real name or that of the town where she lives. "I still feel so much grief and guilt," she tells me. "I don't need the judgment: I judge myself enough already."
She has finally summoned the courage to talk about something that happened to her nine years ago when her daughter, Olive*, was 10 months old. Her story goes to the very heart of one of society's darkest taboos: the private and public shame of a mother who can't take care of the baby she has waited her whole life to hold.
Olive was six weeks old when Asta was diagnosed with PND; her GP prescribed antidepressants. "I'd put up a mask and everyone around me thought I was doing just fine," she tells me. "I felt embarrassed about not coping. I was a nurse who'd looked after children for years: how was it that I wasn't able to cope with my own baby?"
Two weeks later, Asta experienced her first psychotic episode. She and her then husband had just got home after being at church with Olive, who was unsettled and crying continually. As she sat in her bedroom with the blinds drawn holding her screaming baby, Asta became convinced there were people outside watching and that, any minute now, they were going to burst in and take Olive away. Asta went into the lounge, but felt countless eyes on her there, too, this time coming from the flat-screen TV. Becoming more and more distressed, she wouldn't relinquish her hold on her daughter, not even to give her to her father.
Later that day, Asta was admitted, involuntarily, to the psychiatric unit at Flinders Medical Centre in Bedford Park, Adelaide: she'd been sectioned. "It wasn't nice there," she says. "I remember random things. We were shepherded into the dining room at meal times and all the cutlery had to be counted before and after we ate. One night a spoon was missing. None of us could go back to our rooms until it had been found. Turned out they'd just miscounted."
Later, Asta was transferred to mother and baby unit Helen Mayo House at Glenside Health Services, an inpatient facility which she'd revisit at least three times during the next eight months as doctors struggled to find a treatment that would stabilise the worst of her symptoms. Finally, she was prescribed olanzapine, an antipsychotic medication used to treat schizophrenia and bipolar disorder.
In July 2010, her condition suddenly worsened. With her marriage stumbling towards its conclusion, she and Olive had moved back in with her mum and dad. It was an arrangement that seemed to be working until, one night, Olive woke up and started to cry inconsolably. "I just couldn't get her to settle and all of a sudden – I don't know, but something snapped in me – I couldn't look after her anymore. I'd never felt that before, I'd always wanted her. Yeah, that was the lead-up, very sudden and very strong feelings of just not wanting her anymore."
She pauses, the pain of the recollection etched on her pale young face. "She was in her cot and I grabbed a pillow, put it over her face and held it there. Mum and Dad's bedroom was right next door, they'd woken up with Olive's crying and, all of a sudden, Mum heard her cry become muffled … she came running in, she knew something was going on. I let go of the pillow. I don't remember, but she says I told her straight away what I'd done."
The next day, Asta was readmitted to Glenside Health Services for acute, one-on-one care. It was here, during her nurse's scheduled, five-minute break, that she came perilously close to ending her life. She'd had only vague thoughts about it before, she says, but, in that moment, she felt a swift and intense certainty.
"I didn't want to be here anymore," she explains. "I felt 100 per cent that Olive would be better off and Mum and Dad would be better off. I felt I'd put them through so much and this would end my pain and suffering and theirs."
I ask Asta gently what would have happened if her mum hadn't heard the change in Olive's cry that night. "I think I would have completed the job," she says with infinite sadness. "I really do."
Professor Phillip Boyce is head of the Perinatal Psychiatry Clinical Research Unit at Sydney's Westmead Hospital. He tells me that at no other time in a woman's life is she more at risk of developing a mental illness than during the postpartum period. No one knows exactly how or why PP strikes, he says, but it's possible that one or more factors are at play when it does.
The first might be hormonal. In the minutes after a baby is born, the placenta is expelled from the uterus, leading to a 200-fold reduction in the reproductive hormones oestrogen and progesterone in a woman's body. "Some women seem to be exquisitely sensitive to this changing level of oestrogen," says Boyce, "and oestrogen, we know, has a buffering effect on dopamine."
The role of dopamine – the neurotransmitter that conveys signals across the spaces between brain cells – is key when trying to understand the changes taking place in the brain when psychosis is afoot. "Whether too much dopamine is being pumped out in the first place or whether the dopamine receptors aren't working properly, we really don't know, but this [improper level] causes alterations in the way the brain functions and thinking goes badly awry," he says.
Another element could be an acute disruption in the body's biological circadian rhythms, which also has been known to trigger bipolar disorder. "Oftentimes," says Boyce, "a woman doesn't sleep during her labour, then she can't get to sleep in the days after the birth. She becomes increasingly over-aroused and this can also lead to psychosis in a woman who has an underlying susceptibility." Anyone with a personal or family history of psychosis or postnatal mental illness can fall into this category.
A third possible trigger being explored by psychiatrists, says Boyce, is an inflammatory immune response in the brain to the stressors of childbirth. Any one of these factors, acting alone or in combination, has the potential to hurl a perfectly well woman over the precipice of mental oblivion precisely at a time when society expects her to be at her happiest and most nurturing. The shame is immense.
PP still has no listing in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), an omission that one expert I speak to attributes to "politics". Not only does this omission impede research, it makes arriving at the right diagnosis less straightforward: not every woman who's dangerously unwell, for example, will have manic symptoms.
The good news is that most women with PP respond very well to treatment, which comprises antipsychotic medication and, in some severe cases, electroconvulsive therapy (or ECT). "Yes, I know," says the RHW's Marie-Paule Austin, raising her hands in mock surrender, "it sounds like something out of One Flew Over the Cuckoo's Nest. That movie has been such a scourge on psychiatry!"
ECT involves inducing an epileptic seizure under a very light general anaesthetic. These days, Austin says, it's a very safe, refined procedure tailored to an individual's needs. "We don't know exactly how it works, but it's incredibly effective in the right patients. Women start to respond after three or four treatments, whereas an antipsychotic drug can take up to two to three weeks to kick in. It's a short-term treatment, though: a patient will need to be on medication, too, for at least six months afterwards to avoid a return of symptoms."
Many women who recover from PP will stay perfectly well – until they have another baby, at which point the likelihood of a relapse is more than 50 per cent. For others, there's a 15 per cent chance of being diagnosed with a mood disorder (such as bipolar disorder) at some point in the future.
Gabrielle Micallef had no history of mental illness, nor had she ever heard of PP. But none of this mattered as her mind soared and plummeted like a kite in a hurricane while she waited for the olanzapine she'd been prescribed to take effect. After receiving her daughter's mayday text, Frances had driven straight back to the airport.
Gabrielle slept with Frances in a made-up bed in the living room because it was the only place she felt safe; by now she was convinced that she and Andrew were under investigation for poisoning David with baby formula. Everything that she saw now, inside the house and out, supported her paranoia. She could shower, but not dress herself; just doing up a bra was a feat of mental endurance. While Frances looked after Gabrielle and did what she could to protect the fragile mother-baby bond, Andrew, who had an incredibly understanding boss, took care of David. Jane, Andrew's mum, managed the house.
The sedating effect of the olanzapine helped Gabrielle sleep and, as she slept, her brain began to heal. The psychosis gave way, eventually, to a dull depression. "I just felt so ashamed," she says. "I'd always thought of myself as strong, resilient, independent. This shook me to my core."
In mid-2014, after eight months on it, Gabrielle came off the medication ("They told me this illness could take 12 months and I was, like, "Hell, no!" she thunders). She started walking and doing class workouts at her gym: she'd put on 20 kilograms in the time she'd been "away". When David was 10 months old, the Micallefs moved to Gwynneville and Gabrielle was well enough to think about going back to work part-time. By the time David's first birthday rolled around, she and Andrew had found each other again.
Most women in the grip of PP will need to be hospitalised during the most acute phase of their illness. Only a very small percentage of these will be lucky enough to have access to a bed in a publicly funded mother and baby unit (MBU); the majority will be sent to an acute psychiatric ward in a general hospital where the difference in the quality of care they'll receive is likely to be stark. As its name suggests, the function of an MBU is not only to help mums get well, but also to help them overcome any attachment issues they might be experiencing.
Unfortunately, the distribution of MBUs nationwide is patchy at best. Victoria, by far the best-served state, has 35 beds in six units, while WA has 16 in two; there are only six beds in SA, four in Queensland (one unit each) and, incredibly, none in NSW – the country's most populous state – Tasmania, the NT or the ACT. (There's one private, 12-bed MBU at St John of God Burwood Hospital in Sydney's inner west.)
This unevenness frustrates and baffles just about everyone working in the field of perinatal mental health, particularly those who live in NSW, where more than 90,000 babies were born in 2016. "Add them all up and you see that PP, which affects two women in every 1000 deliveries, isn't that uncommon," says Professor Boyce with feeling. "These women need specialists looking after them. They can be floridly psychotic one day and appear to be doing very well the next; you've got to be very cautious."
When I ask Tanya Davies, the NSW government's minister for mental health, for comment, her email is Delphic in its obscurity: "As part of the mental health infrastructure planning process, the Ministry of Health regularly reviews services … such as mental health beds that can accommodate a mother and her baby. This work will inform future investment."
Martin Foley, her Victorian counterpart, underlines that his state is leading the nation in its support of new mothers: "With one in six new mums experiencing mental health challenges, it's crucial we provide them with the help they need," he writes. "That's why perinatal depression is a priority of our  10-year mental health plan." The state's newest MBU, its sixth, opened at Bendigo Hospital last year.
For a woman who has survived one round of PP, the chance of falling down the rabbit hole again after a subsequent delivery is high. When Gabrielle gave birth to her second son, Joshua, on September 29, 2015, at Wollongong Hospital, her doctors advised her to start taking antipsychotic medication immediately, but she preferred to watch and wait. "What can I say?" she says. "I'm a glass-half-full person. I believed it would be different this time around."
It was different this time around. This time, she had to be admitted, in the middle of the night, to the locked ward of the Psychiatric Emergency Care Centre (PECC) at the same hospital where Joshua had been born five weeks earlier. "There's a pub not too far away from our house," she says.
"One night, I heard people walking past our house on their way home. They were shouting and swearing and their voices sounded so loud and threatening and, suddenly, I just felt more frightened than I'd ever been in my life. I was terrified." Andrew didn't think twice: he left the boys sleeping at home with his parents and drove her straight to emergency.
Later that night he had a panic attack. "Yeah, I hit rock bottom," he tells me. "My parents were about to leave to go back to Victoria and I was going to be by myself. I knew what was coming this time and I doubted everything. I thought, 'I'm not going to be able to do this and they're going to take David and Joshua away and maybe that's a good thing.' I couldn't sleep, millions of thoughts were going round in my head. I thought I was going crazy, too."
Was it a difficult decision for him to agree to have a second child? "For me having one baby was a big decision," he says, "and that was before we knew of the likelihood of Gab getting sick. I feel we had a second child mainly for our first. Both of us know the benefits of having brothers and sisters and we felt we'd put in enough protective factors to stop Gab getting sick again." He pauses. "I doubt we'll have more."
Gabrielle recovered more quickly the second time around, although she's still traumatised by the "10 days of hell" she spent alone inside that PECC ward. On the other hand, her brush with madness has made her a better psychologist. "I've been there," she says.
Andrew, too, is damaged in ways that can't be seen: "I get highly anxious around other people's newborn babies. They're a reminder, I suppose, of all the pain," he says. He brightens suddenly. "Gab's illness brought us closer together. We have confidence now that no matter what challenges life throws at us, we'll be able to get through them. Nothing can ever get in the way of the love we have for each other."
In 2012, Asta moved out of her parents' house; she found a place close by and sees Olive, who still lives with her grandparents, every day. She doesn't know if they'll ever live together – just the two of them – again: "I just don't know if I could do it by myself," she says. In the meantime, she has a new partner who has two children from a previous relationship; neither marriage nor another child is on the cards – for now.
No mental illness is more freighted with emotional heft than the one that plays out in the space between mothers and their babies. And PP, with its implications for the safety of a helpless infant, is particularly loaded with judgement. PANDA's national helpline receives 1000 calls a month from women who are finding motherhood a struggle: "Eighty-seven per cent of them," says Terri Smith, "haven't told their midwife or their maternal child heath nurse about their feelings. This doesn't mean that they haven't been asked; it means they haven't been asked in a way that encourages them to answer honestly."
Which is why Gabrielle and Asta have decided to step into the void. Despite being health workers, neither of them had heard of PP until they were diagnosed with it themselves. Their stories are harrowing, but also show that it's possible to punch a hole in the invisible membrane that separates everyday life from unimaginable horror, and live to tell the tale in order to help others. PP is survivable. So survivable, in fact, that Gabrielle Micallef may not have ruled out the possibility of running the gauntlet a third time: "I always seem to come back to the same thing," she says. "You have a lifetime with your children: the madness is only temporary." She bursts out laughing: "Crazy, right?"
* Names have been changed.
PANDA helpline: 1300 726 306; Gidget Foundation: 1300 851 758; Lifeline Australia: 131 114; Beyond Blue: 1300 224 636.