Last year I began working in a hospital in the heart of Amish country. My first Amish patient was an elderly-looking woman, yet her chart revealed she was only 49. Her plain blue cotton blouse was fastened primly down the front with straight pins. Only Amish men are allowed to use buttons; if a woman wears clothing with buttons, she is considered vain.
"How many children have you had?" I asked her out of simple curiosity.
"Thirteen," she said.
The Amish culture is fascinatingly different from mainstream America. I spent months learning about it, but as far as medical care goes, the two worlds have a lot in common. Like anyone else, the Amish brought their children in when they had sore throats and earaches. Their children were vaccinated; elderly Amish wore hearing aids and welcomed pacemakers. They even rode around in cars—they just couldn't own a car or drive one. Many Amish, like most Americans, no longer farmed. In the town where I worked, several hundred had jobs at a local cheese factory. The Amish are not supposed to smoke or drink, but I saw Amish men who smoked and drank, sometimes too much. Some of the women smoked, but only out on the back porch when the men weren't home.
One night I picked up the chart of a 22-year-old woman whose chief complaint was, according to the triage nurse, "three weeks postpartum." This, I mused, was not much of a complaint. I gathered up the chart and my stethoscope and headed toward 4B, which happened to be reserved for psychiatric patients. There in the doorway I found a woman rocking a tiny baby wrapped in blue blankets. The baby was asleep.
"So, how's your little one?" I asked.
"Oh," the woman said, "he's not mine." She nodded toward the cot. "It's her baby. I'm her sister."
On the cot sat a young woman, head down, shoulders sloped.
"What's the problem?" I directed my question to the sister because the patient looked very troubled.
"She wants to kill her baby," she answered matter-of-factly.
I must have stood there for a moment, mouth open, because she hastened to reassure me: "No, really. And she said she wanted to kill herself too."
Postpartum depression. My first thought was, Not among the Amish. I had seen no hyperactive Amish children, no post-traumatic stress disorder, no "borderline patients." I had seen a couple of garden-variety cases of mild depression—mostly, it seemed, mother-in-law induced. Otherwise the Amish seemed to be without the mood and thought disorders that bedevil the rest of my patients.
"She's really bad off," the sister said. "She doesn't eat. She doesn't sleep at all, and she tells me she can't stop thinking about the baby. She's afraid she's going to hurt the baby."
I introduced myself to the patient. "What's the problem today?" I asked.
She shrugged her shoulders and didn't even lift her head.
I knelt down to get a view of the face beneath the bonnet. "Could you talk to me a little?"
She shrugged and said, "I've been thinking bad thoughts."
"What kind of bad thoughts?"
"Bad thoughts about my baby."
"For how long?"
She thought a minute. "This week." After a pause, she said, "I have a little voice telling me to kill my baby. It's an evil baby." She looked up at the ceiling and cocked her head as if she were listening to someone. "No, no," she said quietly.
This was not postpartum depression. This was postpartum psychosis. This woman needed to be in the hospital.
"You're going to lock me up, aren't you? I don't know why. I haven't done anything wrong," she said.
"We need to keep you safe," I said. "I'm not sure you are safe by yourself right now."
"I guess God needs to punish me for having bad thoughts."
"I don't think it's quite like that. I think God is giving us a chance to help you feel better."
"Nothing can help me," she said.
After I left the room, the gloom was so powerful I seemed to carry it with me. I sat down with her chart and mumbled, "Three weeks postpartum . . ."
I knew that unhappiness could follow the birth of a baby. Postpartum blues are usually seen during the first few weeks, when the new arrival upends a woman's world. These "blues" don't necessarily equal a bad mood so much as an unstable one. Women may find themselves convinced one minute that "things are all wrong" and "I'm a bad mother," then suddenly feel on top of the world. Why these moods occur is still unknown. Disturbances in sex hormones as well as the hormones that regulate stress have been suspected, but no connections have been proved.
About one in five women experience more serious postpartum depression, which tends to come later than the blues, often six to eight months after birth. The incidence of depression in women who are postpartum is about the same as depression in the general population, suggesting that having a baby may not be a factor. Treatment is about the same as for regular depression—counseling and antidepressant drugs—although the drugs are problematic if the mother is breast-feeding.
Much more rare is postpartum psychosis, in one or two women per 1,000. It shows up within a few days to a few weeks after birth and is often associated with other psychiatric illness. The only other case I had ever seen involved a woman who was five days postpartum. When I interviewed her, she had been much more agitated, more manic than this woman was. She had lost her ability to reason. Yet she had no past psychiatric history, was happily married, and worked as a dental hygienist. "Bipolar," the attending told me. "No question." Mothers with a history of lifelong psychiatric disorders, such as manic depression or schizophrenia, are most likely to experience postpartum psychosis. An example is the tragic case of Andrea Yates, who drowned her five children. She told investigators that she thought the only way to save her children from eternal damnation was to kill them. She thought Satan lived within her, and if the state of Texas executed her, evil would be eliminated from the world. Such powerful delusions are common among schizophrenics.
The first step in treating the patient is to hospitalize her and get the child into a safe environment. The next step is to treat the symptoms, which may require antipsychotic medication and sedatives.
I turned to look back toward the room where the girl sat. In the coming months I would see a full spectrum of psychiatric diseases in my Amish patients—schizophrenia, severe depression, suicidal impulses, alcoholism, dementia. I was disillusioned. I wanted to imagine that the Amish lived in a world deeply connected to each other and to a spiritual life. I wanted to believe that their world held no mental illness.
I could see the sister standing next to the patient, one arm cradling the baby and the other arm around her sister's shoulders. In the doorway stood a shy-looking young man, probably the husband, and an older man, perhaps the father or a pastor. The patient was crying now, her shoulders shaking. All of them had their heads bowed. I gazed back at them, understanding for the first time that when it comes to hard luck, bad times, and terrible diseases, the Amish are not spared any more than the rest of us.
