A maternal mental health story: Dr Ella Rachamim

Nearly twice as many mothers of twins suffer from post-natal depression as those of singletons. This is the story of Dr Ella Rachamim’s post-natal depression after the birth of her identical twin girls, who were themselves suffering from cows milk protein allergy and reflux.

Both Ella and I appreciate that as a paediatrician with a psychiatrist husband, Ella was in an enviable position to get help. What we hope by sharing her story is greater understanding of the reality of postnatal depression whoever you are and an appreciation of how difficult navigating paediatric and mental health services can be, especially when you’re suffering from anxiety.

Most importantly we hope that this helps more people understand how vital it is to support our perinatal mental health services, for all the parents and families who need help.

When was the toughest time during your twins’ first year?

Between two months and six months was probably the worst time in terms of my mental health, my level of exhaustion and anxiety. I wasn’t able to cope as well as I would have thought and I expected. I had to rely on others just keep it all together.

When did you realise you needed help?

The first thing was l kept thinking that there was something not quite right with the girls. They were feeding and sleeping really well and then at about two and a half months they started to cry a lot more, they were really unsettled and wouldn’t sleep for more than half an hour chunks. They were becoming quite difficult feeders, more and more uncomfortable. I think that’s when I started to get unwell.

I started researching their symptoms and I wouldn’t stop with one person. I would ask and ask and ask, this contact who was a specialist in lactation that I knew, then I might ask another twin mum and then I would ask on forums. I had lots of different opinions, whereas it would have been more useful to have one person to trust. But that was my anxiety, I would constantly start talking to different people and that spiralled out of control.

I stopped sleeping at that point, even when the girls were asleep I would just lie awake. I kept worrying about why they weren’t sleeping and then about what would happen in future. I would go round and round in circles, unable to stop this ruminating. Constantly thinking if this happens what will happen and then what if this happens, never being able to switch off.

The one night that really kicked off they were tightly swaddled like mummies and I just couldn’t understand why they would only sleep for brief periods. It spiralled into catastrophizing — will they ever get out of their swaddle? Are there different types of swaddle I can try? When will we be able to stop it and if I can’t what could be the complications and side effects so swaddling? There was a lot of Googling. It all went round and round in my head and I didn’t sleep that whole night and then they woke up, and the day began again.

I was talking to Hugh [Ella’s husband, a psychiatrist] about it and realising, this is not right, it’s not normal, it’s got out of control. I still held a fundamental belief that there was something wrong with the girls but it was so difficult to fight for them when people just saw my anxiety and neuroses, they wouldn’t understand my deep maternal instinct that something was wrong, that they were in pain.

That went on for two or three weeks. Then I was in a state of constant worry and anxiety, focussing all the time on their routines, trying anything possible to make them sleep. I was obsessed with their routine being absolutely in synch — if I could control the day, I could control the night. If I couldn’t get them back into a routine I was so terrified about this constant, ongoing insomnia and anxiety — I got black-out blinds, put towels along the windows where they was a crack of light, they were swaddled in separate rooms. Everything was about the routine.

We managed to get a night nurse for two or three weeks with the goal of me getting some sleep. Even then I still couldn’t — I was counting sheep, meditating, nothing worked — I didn’t want to take any sleeping pills as I was still breastfeeding.

I was at the point where I would bring them in for a breast feed and they would scream their heads off. Looking back, I can see they were flat in the rugby position and they had acid reflux but then I would wonder maybe they weren’t feeding because I had quite a fast ejection reflex, that the problems was fast flow, then I would read all about that. In the end I was so anxious I couldn’t even pump and the girls were so unhappy to breastfeed anyway so, gradually, I cut down and moved to bottles.

But then they wouldn’t take bottles of milk, only taking one ounce every so often, it was a constant battle to get some milk into them. If they were quite drowsy was the only time they would feed. And at that time I remember the night nurse saying “I’m really struggling, the only time they slept was when they were upright on my shoulder”.

Then I asked my mother in law to come over from South Africa. My son was now 20 months old and there was only so much my own small family could do, we needed help. So I asked her to come back — she’d come for the early weeks — so then she, my sisters-in-law, parents and brother would take turns with the babies. At that point I remember them sleeping for three hours in upright bouncers but never down in their cots. But still all everybody kept seeing was my anxiety — health visitor, doctors, family. The babies looked healthy thanks to the milk we were managing to get down them and when they saw them in bouncers during the day, they were upright and they were sleeping.

I saw a paediatrician colleague at the height of my insomnia and anxiety. I was feeling so low and knew that they were not happy babies. He looked and saw them and said there was nothing wrong with them, just fussy feeders and that I needed to sort out my anxiety. But one of them hadn’t fed for six hours and I knew they had lost some weight based on their birth weight centile.

How did you get the help you and the girls needed?

I remembered one mother from my antenatal classes with Joey saying “I had this woman Janet and she sorted everything out” and asked if I could I have her number. I was also being assessed by a psychiatrist around the same time as finally getting hold of this woman. Janet walked into my house — I looked awful, I’d lost loads of weight, still couldn’t sleep — and I’d just put the babies in their tight swaddles, in their separate rooms with their black-out blinds and I said “I can’t handle this any more, they won’t sleep.”

And then I was about to go upstairs to soothe one she said “No, I’m going.” and she went upstairs, came down and said “They are not comfortable, there is something going on, I really believe you.”

Finally someone believed what I was trying to say. I burst into tears and she gave me a huge cuddle, I knew I was anxious but I knew I was right. She said “She is squirming in there, she’s moving as if something is not right. I think they’ve possibly got a milk allergy and some reflux. I’ve seen it with other new parents and it looks like normal baby symptoms or colic but I really think there is something wrong, you need to get a second opinion.”

We managed to get them seen by a different paediatrician. Two really good GP friends of mine came with me which was a great help as I was finding it hard to string a sentence together. We went through our family history; Joey had cows milk allergy (transient proctocolitis), Miri had a red sore bottom when he examined them – both key features of cows milk protein allergy, but that had never been brought up at the first consultation. This consultant spent a good hour with us, I felt like he understood I was a competent person normally able to make decisions and really listened to everything I said, and he gave me a hug and he prescribed them medicine for cows milk protein allergy and reflux.

What happened after the girls were getting the medication they needed?

To be honest as soon as they were on the treatment I sort of collapsed. I should always have trusted my instincts but when you are exhausted and intensely anxious you lose all your confidence in your parenting ability. I lost my ability to make decisions. Should I give their medicine in the morning or evening? Should I separate them for sleep? Were black-out blinds a good idea or not? Should I wean early and with what and how much? Stuff I knew, stuff I had done with my son, stuff that wasn’t that important in the scheme of basically having normal healthy babies who were now behaving like normal babies but I couldn’t bear the thought, subconsciously, of getting back into the state we were all in the past weeks.

Up to that point I had held it together — I knew that someone had to believe me and they had. The girls got better quickly and needed to catch up on a lot of sleep they had missed in the preceding few weeks. But I couldn’t see that they were fine and still kept thinking something was wrong and obsessing about the minutiae of their routine. I still struggled to sleep and would wake really early, at 4–5am with severe panic, drenched in sweat, filled with absolute fear and dread which was really hard to stop. It was a fear that is so wretched, I would not wish it on anyone.

Still the girls went from strength to strength. They were always milk and bottle averse, however, they knew that milk had made them have pain so we would put milk in porridge and food. They never enjoyed their bedtime bottle — we would give them a bath, put them to bed, then when they were a bit drowsy manage to give them some milk.

But I was still unbelievably anxious, I had stopped eating, and my mood was very low. I wasn’t tearful but I took no enjoyment in anything. Our friends and neighbours were very supportive, by this stage because of the reflux, we’d started to wean early which was going well and they did loads of food preparation for me, they would take Joey out, or the babies for a walk. I found it hard to sleep when I was in the house so sometimes I would sleep at my neighbour’s house! They were amazing. Hugh was a fantastic help, practically taking time off, his boss was great.

Then, finally, some increased levels of medication made a difference. Thanks to four different types, I could sleep and my anxiety levels started to come down. Thoughts of running away, intense soaking sweats at 4 am — slowly all that went away, but I had to be on medication to help that happen (it took about two years to come off entirely with my anxiety still coming and going). Pregabalin was life saving for me, at the time it was a new medication and I’m grateful to the local psychiatrist who agreed to prescribe.

What was the hardest thing about this time?

The hardest thing is when you are so exhausted and anxious it’s really hard for other people to see beyond that. People knew what I was like in my previous work and role and I wasn’t like that with Joey . Everything was really hard because I was totally off the planet with anxiety.

What advice would you give to someone who is worried about post-natal depression?

Now I do the antenatal course for parents of multiples I am really adamant on planning your childcare in the months after birth. Which friends and family can help and when will they help? Can you afford any support at home? What can you do to optimise your mental health and your sleep? I always emphasize the importance of getting out, being outside, meeting up with others. But also believing in yourself, listening to your parental instincts whether you think something isn’t right with you or your babies and seeking help. We really should value that more.

It would be great if everyone talked more about issues we’ve had and medication we’ve taken! I’d really like to remove any stigma around medication — I was able to enjoy more of my babies’ first year thanks to the right medication. If you keep delaying it then you will have less of that time with them. I’d also like to reassure parents that they will come off the medication, usually it’s just one episode.

I also want other parents to know that the girls have thrived ever since that time and we have an amazing relationship, a fantastic bond. I have never felt guilty about that time and no one else should feel that way (I know some do). I had some really good people caring for them, they always had emotional support and love from family members. I’m also pleased my relationship with older son is also very strong.

I really felt my post-natal depression was biological and situational. You cannot avoid the biological reaction but I did not have enough support in place, I’d been so worried about the pregnancy that I hadn’t psychologically prepared for any other issues as the babies grew.

If people want to help others in similar situations now then support your friends and family, share your stories and advocate and push for local NHS services in perinatal mental health, they make a massive difference.

Dr Ella Rachamim is co-author with me, Louise Brown, of Be Ready to Parent Twins.