Sleep: The First and Best Postpartum Antidepressant
Updated: Jul 14, 2021
I sat up on the narrow bed in the dark and looked at my pager: Potassium of 8. I tried to think what was the significance of this. I turned on the bedside lamp. It was 3 a.m. Potassium of 8, potassium of 8. The words had a rhythm to them. They rhymed with freight and weight. My immediate concern was how they connected to the only question in my mind: Could I go back to sleep or couldn’t I?
On call overnight in the hospital, early in my intern year, I had worked a 16-hour day before taking a break for a late dinner at the hospital cafeteria and starting to respond to the pages that circled relentlessly until a period of radio silence around 1 a.m. finally allowed me to doze off. I awoke in a state of delirium, having to talk myself through the decision-making process. It’s not enough to check on your patient in the morning, you have to get an EKG. You need to get an EKG to look for peaked T-waves, and then you can go back to bed. You have to check to see if they’re having symptoms. You have to check. I had to bargain with the sleep-hungry side of myself that argued the insufficiency of the page to interrupt the depths I had been floating at. In the middle of the night, the atmosphere in the little room was strange, and details that seemed clear and indubitable at 6 a.m., at 3, were indistinct and hazy.
I picked up the phone and called the nurse who had paged me. I put an order in the computer, I reviewed the patient’s recent bloodwork. I did the checking I had told myself to do. This was not a tricky judgement call, just an obvious response to a clinical scenario that would not have given me pause at 5 or 6 a.m. I did the correct thing, but I never forgot how I had to talk myself through something so simple. And I never forgot how much easier those difficult nights of call were than the relentless, chronic, unending wake-ups in the middle of the night for my children.
In responding to pages in the middle of the night, I was prepared. I had marked this evening down on my calendar, knowing both that it would be hard and that there was an end in sight. There was a definite time until which I had to make it and after which I would be free, walking dazedly to the parking lot in the early morning air, no longer shackled by responsibility. Upon hearing a cry in the dark, there was no such guarantee. There was no box I could put a check through, showing that work had been done and completed. There was no knowing whether I would be up for 20 minutes or 2 hours.
Uncertainty of the amount of devastation this would inflict upon me the next day made wake-ups for my children far worse than caring for sick patients as an inexperienced intern. In the hospital, there was some degree of control: colleagues, a handoff, a vacation coming up in a few months. At home, there was none. There was no telling when the magical stage of sleeping-through-the-night would arrive and no time when I would take off my parenting coat and leave it hanging on the door.
When I first ask postpartum patients to tell me about their sleep, they respond in general terms, “it’s ok,” or “I’d like to get more.” What I want is the specifics: “When did the baby first go down, when did you go to sleep, what time was your first wake-up, how long were you awake, when did you go back to sleep and for how long…and then?” I think of myself as a sleep mechanic, listening for clues to a system that’s not running the way it should. I jot down the details and then work with my patient to clarify all the causes of sleep disruption and find windows of sleep opportunity. Yes, it often involves someone else in the household waking to help. Dishes and laundry being left undone. Work not always finished, or not always done to the degree it was before a baby joined the household. Changes to the carburetor.
I tell my patients that the most effective antidepressant in the world will not work if the brain is not getting sleep. That sleep deprivation is a well-known method of torture used to impair cognition and extract false confessions. And that sleep protection is often the first and best postpartum antidepressant.
Sometimes a patient I’m treating listens and makes changes right away. Sometimes it takes longer because she doesn’t yet believe in her ability to make changes happen, she’s lost faith in the ability of others to help, she doesn’t fully accept the connection between sleep and mood, or quite often, has a hard time not sacrificing herself for the sake of everyone else. I argue the reverse: we can care best for others by keeping ourselves in good working shape, not by running the engine dry.
However long it takes, once the dial has moved from very insufficient sleep to more sufficient sleep, I can often see it in her face. A smile before she even starts talking. “I’m feeling more like myself.” Sleep – a restoration it’s beautiful to see.