Madness, medication and motherhood

I have bipolar disorder. I want a child, but I am terrified of going off my meds -- and of birth defects. Do I dare trust this body to create another one?

By Maud Casey
April 3, 2006 1:50PM (UTC)
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In the trees, the sci-fi chirring of the seventeen-year Cicada's call to mate haunts the air. May 2004: war and now, but of course, pestilence. Here in Baltimore, where I've landed in my nomadic thirties, the Cicadas lie spent on the sidewalk, fluttering one post-coital wing for hours before they die. With their buggy red eyes and cartoony paned wings, they careen lustily into car windshields, leaving behind a sticky smear of longing that no amount of window wiper fluid can erase. One of them (Pre-coital frenzy? A swoon of dying delirium?) flings itself into the arm of my windshield wiper as I drive down the road and I leave its corpse stuck there for days out of a kind of admiration. These fiercely determined insects seem symbolic, important. A symbol of what? Biological destiny? Perseverance? I imagine they have something to tell me, a thirty-five year old woman who may someday want to have children. After seventeen years of muffling their Cicada desire deep in the dirt, these determined insects have risen from the earth on the same night with a sole purpose: to breed. All day long, that sci-fi chirr, a plea in the trees, where they've instinctively climbed from their underground burrows to molt and get it on. The male Cicadas vibrate their timbals, drum-like abdominal membranes. Chirr, chirr. Let's do this thing and make more of us to burrow deep and rise to do this thing again.

The seventeen-year Cicadas are also known as Magicada and there is, in fact, something magical about their trilling refrain. It's not a question. In the face of the resolute nature of nature, my own quandary over whether or not to have children takes on a poignant human quality. No, the Magicada are unfettered and uninhibited in their commitment to their evolutionary task. They don't wonder whether they should bring their bug children into an overpopulated world of torture, natural disaster, poverty, disease, cruelty, injustice, not to mention the sometimes numbingly banal trudge, trudge of just getting through the days. They don't wonder how they'll afford it all or whether they'll be good parents because parenthood isn't part of the deal. For them, there is no why. Their mission is pure: rise up, breed, and die. I can't help feeling a slightly bizarre twinge of jealousy for the chirr, chirr in the trees outside. The female Cicada will lay between 200 and 600 eggs that will hatch into Cicada nymphs who will burrow deep, suck the juices from trees in order to survive for seventeen more years. In the seventeenth year, the nymphs will climb the trees and emerge from their split skin to begin the chirr, chirr and find female Cicadas with whom to mate. Burrow, rise up, breed, die, repeat. In the throes of my reproductive years, surrounded by friends who are new parents or on the verge of parenthood, the Cicada's song has a keen resonance. Lurking behind the buzz in the trees, I hear a different sort of sweet biological chirping: will you or won't you? Will you or won't you?


But for me, the question of how to be pregnant occurs simultaneously with the will I or won't I, the why and the whether. At the age of eighteen (around the same time the last batch of recently hatched Magicadas had gone underground to nourish themselves with the juice of trees), I was diagnosed with bipolar disorder. Ever since, I've been taking medication to prevent a relapse into the whirling circus of psychosis and mania, where, among other things, my mother was disguised as Madonna sending me messages through her videos, and wearing shoes meant you walked on souls (soles). This medication also prevents another foray into the dead land of depression where the idea of my mother-cum-Madonna seemed like the good old days and putting on shoes took all of the energy I could muster, never mind worrying about trampling spirits. The bipolar disorder is located somewhere between my animal body and my human mind, a combination of genes that have ingeniously conspired with that various and complex thing called life to create a chemical imbalance and I am down-on-my-knees grateful for the relief the medication brings me. I often find myself staring at the drugs in my cupped palm in amazement and wonder: Lexapro, an anti-depressant, is a tiny white bitter-but-blissful tablet; the anti-depressant Wellbutrin is a curvaceously round, pink cheerleader of a pill; and the Stepford-wife sounding mood-stabilizer, Tegretol, is a humble medium-sized pill that looks deceptively like a run-of-the mill aspirin. My marriage to this medical cocktail has been a relatively stable and happy one and pregnancy would require a separation. The most alarming aspect of this separation is the break from Tegretol, that miracle aspirin that keeps my moods, well, stabilized.

According to various studies, if a woman takes Tegretol during the first trimester of pregnancy, there are risks: a 1% risk for neural tube defects, such as spina bifida (versus the .01% risk associated with women not taking Tegretol); an increased risk of heart malformations, cleft lip and stunted growth (particularly in head size); and, bizarrely, a heightened risk of abnormally large spaces between the nose and upper lip. The research is incomplete and hard to come by because there are ethical considerations, more risks, involved with doing research on pregnant women.

There is also evidence that the more depressive or manic episodes a woman has had, the more likely she is to have another. In other words, there's a cumulative effect, a building of one upon the other, like sedimentary layers. There have been studies in which over half of the women observed relapsed into the whirling circus when they went off their medication during the first trimester of pregnancy. Questions beget questions. Will I risk my hard-won mental health for motherhood? Certainly there will be scientific progress. There are National Institute of Mental Health initiatives dedicated to finding mood-stabilizers that are less dangerous during pregnancy. Women with bipolar disorder can, and do, work closely with psychiatrists and therapists during the first trimester to monitor mood shifts, to keep track, to balance the risk of relapse with the risk of birth defects. So let's say that I will risk it. Let's say I begin to consider the why and the whether. Again, the answers are questions. What if my child, having been spared spina bifida, a deformed heart or a tiny nose, inherits the worst version of my haunted genes and it turns out that he or she is shouldering the 10-15% risk of suicide that accompanies bipolar disorder? How do I assess that ephemeral feeling of mania, see it through the eyes of my child? The day I sat on my bed as a freshman in college and felt for the first time something alive rising in my throat, terrifying and exciting, slippery silver like mercury streaking up my throat, the elusive thing that later would be identified as a disease? This becomes something wholly different if that hard-to-pin-down feeling might be passed on to my child in some form. How do I measure the sub-lingual, elusive grind of depression, the days of staring at my bedroom ceiling, its blankness a generous projection of my mind? Because when I think of having a child, I fear the day I look into her eyes and realize the unquantifiable "it" of bipolar disorder is in her too. The day I realize that, knowing the risk involved, I did this to him. Will I risk the mental health of my unborn child? Like the branches of bonsai trees, the questions loop back on themselves to the central trunk: why would I want to have a child? Before the questions, there is history, the history of imagined and accidental pregnancy. Chirr, chirr, a rattling of my grown lady timbals, a fugue in three parts.


1986: The Rise from the Earth, Part I
Wherein I mourn the blood that blossoms in the toilet bowl and refuse sanitary napkins from the nurse in the university infirmary though my underwear is soaked with blood. The nurse tells me she's not going to change the sheets until I agree to wear the sanitary napkins. I've made my bed and, well, I can lie in it. Her sentences are sharp, slicing through the air, devoid of the usual softness of that clichi. In this clipped, unyielding voice, she speaks often about choices -- to sleep or not to sleep, to fight the sleeping pills meant to sleep me through this part until the part when my parents arrive to take me home. I've had my first manic episode though no one knows it yet. The consensus so far is that this unusual behavior may be the result of experimenting with drugs or brought on by lack of sleep, neither of which are unusual for a second-semester college freshman. There is an authority to the nurse's voice like a wall that my slippery silver mercury mind leans against gratefully, but she doesn't understand, and I can't explain. I am pregnant and I am dying. I'm not sure if I say it out loud. It's a poetic declaration that I refuse to surrender. Until today, when the blood tells me that I'm miscarrying, that I'm losing the baby.

"It's your period," the nurse says. Clearly, I have said something out loud. She waits outside the open bathroom door, her back turned to me. Suicide watch precludes closed doors. "I'm not going to say it again," she says, though she just has and she will. Her smile is more unfriendly than her regular face, which is reassuringly and determinedly expressionless. I return to lie in the bed to bleed out my phantom baby. Outside the window, students walk along the trimmed paths, backpacks slung over their shoulders, on their way to class in the gauzy beginnings of the spring light that's come to swaddle the remnants of cold winter air. I bleed and wait for the public safety officer on night duty who, for the past several nights, has sat by my bed and talked about God, His goodness, His greatness. I don't think I believe in God, but the phantom baby is close to something bigger than myself, something spiritual. The public safety officer is a tall, thin black man with high cheekbones set in an angular face and an orange-ish Afro that escapes the sides of his public safety hat as if it is flying away like the angels he speaks about. The night shift begins when everyone else goes home. When he returns home in the morning, his family -- he has a wife and three children, he tells me -- has already left for the regular daytime world. He lives an opposite life that I can relate to. Together, I imagine, he and I exist outside of time. We are transcendent, like the child my mind has conceived on the heels of first love. "God loves you," the public safety officer says, and when I tell him that I'm losing my baby, tears run over the sharp bones in his face and he holds my hand, laying long, spindly fingers across my own short ones soon to be fat from medication. "I'll pray for you and your lost child," he says.

He knows there is no lost child. The nurse told him in one concise, chiseled sentence as she headed out the door, explaining the thick pad placed between my body and the mattress. But he was generous, willing to respect my hallucinated pregnancy, this excess of feeling. Beyond the hot blood zing of mania, the rush of psychosis to make signs and symbols out of every dull scrap of life, did the excess of feeling have something to do with a desire to create life? Or did it have more to do with a desire to grow up? Something in me wanted to go beyond myself the way this man with real faith seemed able to, crying for me, a crazy girl yearning wildly, recklessly, for a tangible tragedy, blood she could see. At eighteen, when I couldn't see into my future, when I couldn't see much of anything except myself, the possibility of having a child, the idea of it, felt powerful.


1998: The Rise From the Earth, Part II
Wherein the nurses at the psychiatric hospital tell my family I've been restrained because I smeared menstrual blood on the walls of my room. Several weeks into my second hospitalization for bipolar disorder, I've been restrained several times. When this happens, my arms and legs are belted to a gurney so that I can't move in any direction. I have a memory of being upside down as mental health workers secured my arms and my legs, but I don't think that really happened. I don't remember smearing my menstrual blood on the walls of my room either. What I do remember is that I believed I was miscarrying again. I bled and years of anger and sadness were focused to a sharp point of grief that became the loss of the second phantom child I believed I was carrying. Again, an excess of feeling, a bursting of love in my head bursting for so many things, but the biggest explosion, the one that seemed the most palpable was for this lost child. (Years from my first love, the father of this child depended on the direction of my nostalgic hyperbole on any given day -- yes, yes, that one-night stand during that year of temping and too much drinking, he's the one.)

Who was this imaginary kid? The pattern of delusional pregnancies are rich material for my therapist but beyond that, and beyond assigning importance to random men, or perhaps behind, or next to these things, there was something about the idea of being pregnant, even in my psychotic fantasies, that was empowering. It was mine, more than mine. In a funny way, it felt as though I were escaping my body, transcending it. But there was no escape, except for the blood on the walls translated into a child, and maybe my body, its blood coursing at that point for over ten years with various life-saving medications -- psychotropic drugs, SSRIs, mood-stabilizers -- had a hunch that down the line when the question of real children came up, so to would the question of the inheritance of these spooky genes. You might not be able to do this pregnancy thing, my coursing blood might have been saying, rehearsing fearfully. Prepare yourself. Practice this loss.


2001: The Rise From the Earth, Part III
Wherein Tegretol reduces the efficacy of the birth control pill by 3%. This information is provided in the Drug Interaction section of the pharmacy pamphlet that accompanies Tegretol prescriptions. It is also provided in the Drug Interaction section of the pharmacy pamphlet that accompanies birth control prescriptions. In 2001, I'd refilled my Tegretol prescription approximately forty-eight times (Tegretol was fairly recent, after ten years of Lithium and a month of Neurontin) and my birth control pill approximately eighteen times. I never once read these pamphlets. Over the years, I'd grown accustomed to leaning on the hard wall of authoritative voices like the nurse's in the college infirmary. I leaned willingly, eyes closed. I'd been taking medication for fifteen years and I never investigated my own illness, grew suspiciously sleepy the second paragraph into the books dedicated to exploring the mystery of bipolar disorder, never researched the medications that ran through my blood. I assumed that hard wall of voices, the they (who were "they" exactly?) to whom I had gratefully turned over the reins, would intuit and intervene if there were a problem, and no one -- not my gynecologist, not my primary care physician, not my psychiatrist, not my therapist -- mentioned that Tegretol decreases the effectiveness of birth control pills and I never asked. It didn't occur to me. At thirty-two, an age when many of the women I knew were trying to get pregnant, some turning to fertility treatments, I found myself accidentally pregnant.

When the pink line appeared in the tiny window of the EPT, I didn't experience the clarity of vision, the rush of power and certainty, that feeling of transcendence, that came with the phantom babies. Instead, it was as if I had been visiting this Econolodge body of mine and now wanted to sneak out having wrecked the motel room. The choice was clear, the only sensible thing to do, my boyfriend of two years and I agreed. At the time I lived in an eleven-by-fourteen studio in Fort Greene, Brooklyn. There was my financial insecurity to consider, his financial insecurity, and our inability to negotiate our relationship, but the bottom line, that relentless cement foundation against which I kept knocking my head, was my medication. "You can't go off your medication," my boyfriend said, and for the millionth time, I agreed with this assessment, resting my weary, guilty head against that familiar wall of hard, official sound.

My period was irregular with the birth control pills. It wasn't unusual that I would skip a period or two. But when I took the EPT test, I was thirteen weeks pregnant, as pregnant as several friends who had recently called to tell me they were far enough along to feel safe letting people know. (Again, no dearth of material for my therapist.) I wanted my boyfriend to love me more than he did and maybe there was a Kamikaze way in which I wanted to be pregnant. But there was more to it than this. Why had I ignored my body for so long? This is the part of the fugue that is the most difficult to sing because my voice quavers, more of a squeak than a song: I was willfully estranged from my own body, and I had been for years. I wasn't so much married to my medication, as I was its child, as eager at thirty-two as I was at eighteen to escape my corporeal self.


I was far enough along that I received general anesthesia when I had the abortion. I didn't think about my uneasy relationship to my body, or birth defects, or God-like power. I didn't think anything at all. There was no excess of feeling. There was me and four teenage girls changing in a small room behind screens into hospital gowns; there was waiting side by side in orange plastic chairs until our names were called; there was tinny Top 40 music playing on a radio in the room as I counted backward; there was deep, dark anesthetized sleep; and there was waking up in a different room with the same four girls, one of whom was vomiting into a bedpan.

My gynecologist did a sonogram before she sent me to the clinic (because she was not allowed by the hospital who employed her to perform abortions), and in a move that still puzzles me, she printed it out and gave me a copy. It was then, with the generic, grainy moonscape snapshot in my hand, that I thought neural tube defects, heart malformations, oral cleft and urinary tract deformities, facial abnormalities. At the center of the moonscape sonogram was the fluid comma, the beginnings of shadow limbs, a shadow head. I've never doubted I did the right thing, but I carried that grainy photograph in my purse for days. I was horrified that this shadow being might have been deformed by the very medication on which I relied, that I'd subjected it to this possibility for thirteen weeks. When I was eighteen and again at twenty-nine, imagining pregnancy was part of an effort to jump ship, but after thirteen weeks of the real thing, I realized that having a child would require that I stop trying to throw myself over the railing, that I stay on board. It would require that I really inhabit this body of mine, but not only did my body seem more real than it ever had before, but my diagnosis did too. I wouldn't be able to lean against the wall of voices because as a mother, "they" would become me.

Soon after the abortion my boyfriend told me he didn't want to have children. I pulled the sonogram out of the file in my office where I'd tucked it between papers. I stared again at the comma curve, its cells halted in the course of their dividing and dividing, and thought, this is it. This is as close to motherhood as I'll ever get. A friend of mine, a mother for eight years, said to me recently that she'd gone to see The Addams Family with her daughter and that something in the cartoon characters' celebration of doom and gloom made her nostalgic for a quality in herself that she considers pre-maternal: self-destruction. She didn't mean that there aren't self-destructive mothers, or that motherhood was a magical land of self-love and rose-smelling diapers. She was talking about something else, a rise from the earth, an occasional distance from your self. A distance that, say, might encourage you to not spend an inordinate amount of time staring at the sonogram of an aborted fetus.


The sonogram is gone and the boyfriend is too. These days I'm free to imagine the levitation involved in motherhood. I think of the book of poetry by Wislawa Szymborska that I marked up with magic marker the second time I was in the hospital. The markings are wild and cryptic, childlike. The ink soaks through the pages where certain lines are underlined two or three times. One of my favorite Szymborska poems, "Grace," is free of my frantic graffiti. The last stanza is a different kind of search for meaning. It's an appreciation for the miracle of someone else's survival. So you're here? Still dizzy from another dodge, close shave, / reprieve? / One hole in the net and you slipped through? / I couldn't be more shocked or speechless. / Listen, / how your heart pounds inside me. If I figure out the how and the why and the whether, and someday I have a child, and somewhere between her animal body and her human mind a combination of genes conspire with life to create silver mercury that rises in her throat and then steals that mercury so that there are only blank walls, I want to remember this poem so that I can offer it to her.

Chirr, chirr. And so on and so on and so on. The cycle is so simple and pleasing, so foreign to this human in her animal body.

Maud Casey

Maud Casey is a fiction writer whose work has appeared in The Threepenny Review. She is a regular contributor to Salon.

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Abortion Mental Illness Motherhood Pregnancy