I always pause when someone asks the question: “Didn’t you always want to be a mother?”

No. No, I did not.

I have always liked children. My education and career have centered on children’s welfare and development. Never did I fear that children would “hold me back,” personally or professionally. I even enjoyed spending spare moments with kids.

My hesitance about parenthood stemmed from my own childhood trauma and the state of my mental health. Specifically, I had two fears: That my mental illness would make me a terrible parent and that the genetic odds of my kids grappling with mental health conditions seemed too high.

I Believed I Couldn’t Be A Good Parent

I live with bipolar disorder. Caring for myself — which includes regular therapy, medication, making space for grounding and re-centering myself — requires significant energy, intention and time. How could I expect to give a child or children the energy and attention they deserved? Even when healthy, I was plagued by thoughts of dread. When I was not healthy, my thoughts were downright terrifying.

In adolescence and early adulthood, my manic episodes shed light on what I believed to be personal shortcomings that would prevent me from becoming a good parent. While manic and hypomanic (and amid delusions and feelings of grandiosity) I was not usually reflective, but in the moments when I was, I felt regret and shame over my self-centeredness. In those moments, I doubted I would ever be a suitable parent. Would I put them in danger, as I often put myself? Would my erratic behavior damage them?

When I had depressive episodes, my thoughts about parenthood were filled with dread and gloom. What if I died by suicide and abandoned them? Even if I was physically present, would I be able to care for them? Getting out of bed, folding laundry, feeding myself and bathing felt unmanageable when I was depressed. If these acts were too much for me, how would I possibly meet the needs of a child? And how could I provide enriching experiences and joy to a home?

Underlying these thoughts was deep self-doubt and the sense that I somehow didn’t deserve children.

Changing My Mindset Required Work

I have two beautiful, healthy children. What changed? In some ways, the shift felt abrupt. One day, I woke up and just wanted children, though I know that the journey required much more work and self-reflection than that.

In the fall of 2008, I experienced a hypomanic, borderline manic episode. In my second year of graduate school, I found myself overcommitted and stretched thin: Too many courses, a 50-mile commute, training for a marathon, taking swim lessons, teaching, performing research and more. Autumn is always a precarious time for me.

The rustle of leaves, vibrant colors, excitement about a new school year, cool wind whooshing in my hair — these typically beloved and highly-anticipated seasonal changes lead to a loss of grounding for me. And in the past, I would not even realize when I started to escalate toward mania.

I distinctly remember the day my perspective began to change. It was the first cool day of the season, but I was still wearing shorts. As I walked across campus, mesmerized by the movement made by the wind on the ruffles on my shirt, a thought snapped into focus, “Oh, this could become mania. This could become very dangerous. I am already pushing myself too much.”

I walked right into the campus counseling center. There, I started therapy, in what was the longest consecutive stretch of treatment I’d ever had. During this time, I received psychodynamic therapy to work through traumatic events from my youth and uncover how they fueled my fears about parenting. As I progressed, my self-doubt decreased and my capacity to imagine myself as a parent grew.

Being The Best Parent I Can Be

I love my role as a parent, but parenting still terrifies me. Being a parent with a mental health condition terrifies me. Some of my earlier fears weren’t unfounded. A parent’s mental health condition presents the possibility for negative impacts on children. However, harm is not inevitable. In fact, I believe my history has made me a better parent.

I practice vigilance when it comes to my symptoms, and I never take my health for granted. Diligently, I put routines in place that keep me healthy, and I model these behaviors for my children. For example, I have established evening routines that create conditions for healing and stabilizing sleep. Our whole family has now adopted them, too.

Chances are, you haven’t heard other parents or caregivers talk about their struggles with mental health conditions. You may have heard about their children’s challenges with mental health, but not their own. If you are a parent or guardian, or considering parenthood or guardianship, and have a mental health condition, you are not alone. If 1 in 5 adults grapples with a mental health condition and roughly 40% of households have children under the age of 18, the math suggests that there are many of us.

Parents and caregivers living with mental health conditions should be empowered to come out of the shadows. Doing so creates conditions for a supportive peer community and for parents to get the care we need to be the healthiest caregivers we can be.

Nicole Beeman-Cadwallader works with a group of students with lived experience with mental illness as a part of a 4.0 Schools fellowship. Together, they are co-designing a training program for peer-to-peer mental health recovery supporters, specifically addressing LGBTQ+ individuals and students of color. She can be reached at nbeeman22@gmail.com.

In a recent study in the American Psychiatric Association’s “Psychiatric Research & Clinical Practice,” lead and senior authors Christine Lu, M.Sc., Ph.D., and Stephen Soumerai, Sc.D., probed further into FDA public health advisories and “black box warnings” that were issued beginning in late 2003, 2005 and 2007. The advisories cautioned that children, adolescents and young adults taking antidepressants were at an increased risk of suicidal ideation and behavior.

The team produced the first long term study of suicide deaths following these warnings and their unintended effects. The Advocate spoke with Drs. Lu and Soumerai to learn more about the study: “Increases in Suicide Deaths Among Adolescents and Young Adults Following U.S. FDA Antidepressant Boxed Warnings and Declines in Depression Care.”

Q: These “black box” warnings about the risks to youth and young adults persist today. Can you tell us how the FDA arrived at this conclusion and what the warnings were intended to do?

A: The FDA issues warnings based on a variety of evidence about drug safety issues, from single case reports to randomized clinical trials.

In this case, there were anecdotal reports that people taking Selective Serotonin Reuptake Inhibitors (SSRIs) and other antidepressants were more likely to have suicidal thoughts and behavior. However, the direction of causation is unclear: Youth taking antidepressants were almost certainly depressed in the first place, sometimes with suicidal thoughts.

Meta-analyses of industry drug trials — which were the basis for the warnings — found a 1–2% increase in the number of young people experiencing suicidal thinking at the start of their antidepressant therapy. However, these meta-analyses were biased. The majority of the trials had neither clearly defined measures of suicidal thoughts, nor ways of accounting for the many people who dropped out of the study, which distorted the findings.

The goal of the warnings was to alert clinicians to look for increased suicidal ideation early in treatment in individual patients. Unfortunately, the warnings stigmatized mental health care for young people. As mental health care declined, correspondingly, suicide attempts and suicide deaths increased in the U.S. population.

Q: Tell us about your journey to study the results of these warnings. What inspired the research, and why have you stuck with it to this day?

A: We realized we had data in the Health Care Systems Research Network (HCSRN) to rigorously address some important unanswered questions about the impacts of the antidepressant warnings. Depression is one of the leading causes of disability worldwide, and some psychotherapies and medications have proven successful in reducing symptoms.

Only a few years after the warnings, several scientists began reporting that the warnings about antidepressants were causing unintended, large reductions in identification of depression, mental health visits and antidepressant use among youth, even among people with major depression for whom these represent first-line treatments. And these effects “spilled over” to adults and elderly people as well. At least three studies showed that the prior downward trend in youth suicide deaths may have reversed.

However, the later studies only included one or two years (of observations) after the initial warnings, so these findings were only suggestive. So, we began work on a large NIMH-funded project to study the longer-term consequences of the warnings. We found that the warnings likely caused underuse of essential care, including substantial reductions in antidepressant use and increases in suicide attempts.

Q: Tell us about your findings. Did they surprise you?

A: No. We observed large increases in suicide deaths among adolescents and young adults following the widely publicized FDA antidepressant warnings and reductions in mental health care.

The FDA antidepressant advisories, accompanied by media coverage, stigmatized depression care for young people and fostered reluctance by providers to initiate antidepressant treatment. Thus, these warnings reduced diagnoses of major depression, and drug and non-drug mental health treatment.

Furthermore, 60–70% of adolescents and young adults with major depression do not receive any mental health care. While inappropriate use is certainly a concern, the major problem appears to be underuse, not overuse.

This data supports a formal reevaluation of the harms and benefits of the antidepressant warnings. The risks of suicide deaths caused by untreated or undertreated major depression following the enactment of the FDA warnings are even more alarming than the risks of suicidal ideation that may be associated with specific antidepressant drugs. We recommend that the current boxed warnings, the FDA’s most severe warnings about a drug or drug class, be lifted entirely or “demoted” to the long list of routine warnings contained in product labeling.

Q: What is unique about this study?

A: This is the first long-term study to investigate whether suicide deaths in the U.S. increased among adolescents and young adults following the antidepressant warnings and the accompanying declines in depression diagnosis and treatment already demonstrated in large quasi-experimental studies.

Q: Your study addresses the increase in suicide deaths, while other studies using the same methods have shown that the warnings caused outcomes that typically precede suicide. Can comparisons be drawn between these studies, especially in relation to the timing and shape of the effects of these studies?

A: Yes. A number of strong interrupted time-series studies (led by Libby, Busch, and Gibbons, to name a few) showed that the warnings reduced diagnoses of major depression, and drug and non-drug mental health treatment; these are intermediate outcomes that predict suicide. This data adds to the evidence of an association between the antidepressant warnings and increased suicide deaths.

The most striking intermediate outcome was the increase in suicide attempts demonstrated by our study in the BMJ in 2014. Our recent study mirrors and supports this earlier study of suicide attempts following the FDA warnings. The only difference is that we documented actual suicide deaths.

Q: Are there implications of your study for policy advocacy at NAMI?

A: To help support the needs of young people with depression, NAMI has an important role to increase awareness that individuals should adhere to psychotherapies and medication treatment as prescribed by their clinicians. We also strongly urge NAMI leadership to help support the FDA’s reevaluation of the antidepressant boxed warnings to convert these severe warnings to routine warnings. Strong data from different rigorous studies are now available to confirm that the existing boxed warnings are causing more harms than benefits, including reduced access to first line psychotherapy and medications, increases in suicide attempts, and increased suicide deaths.

Stephen Soumerai is a professor of Population Medicine and founding and former director of the Division of Health Policy and Insurance Research, and he teaches research methods at Harvard Medical School.

Christine Lu is an associate professor of Population Medicine and applies rigorous quasi-experimental research methods in her research.

Note: This article was originally published in the Spring 2021 issue of the Advocate.

I began my mental health journey 40 years ago, when I was diagnosed with bipolar disorder I. Outside of therapy and medical appointments, I had no one to talk to about what I was going through, so I began journaling as a means of self-expression and to let out my pent-up feelings.

While writing was an important outlet, I truly found solace in listening to music. Listening to music could soothe me in a way nothing else could.

The comfort I found in music is not surprising. Studies have shown that music in its various forms has therapeutic and medical value. The impact of music extends beyond the scientific literature; I have heard the stories of people whose emotional well-being has benefitted from formal music therapy — or even listening to a playlist of songs that they connect with mentally and emotionally.

When I was struggling, alI I needed to do was put on an album or cassette (and eventually CD and mp3) and let the sound do its work. I wouldn’t just hear the music; I would feel it in my heart and soul. The melodies and rhythm of the songs I listened to combined to lift my mood and made me feel exuberant.

My Recovery Had Its Ups And Downs

As I developed coping mechanisms for my symptoms, I was able to gain a semblance of stability — and music remained a central part of my life. I even went on to work at my college radio station and a Buffalo-area reggae club, Rude Boys Roots Rock Café. Eventually, I graduated with a degree in broadcasting. After graduation, I got a job at a local recording studio.

About four months after I began my new job, my life shifted drastically. I veered away from my treatment plan (I was drinking and using illicit drugs), and I faced the prospect of another hospitalization due to my non-compliance. I made the decision enter a 12-step program, which has been the single most important decision I’ve ever made for my recovery. I was able to find the stability I had always hoped for. This newfound balance allowed me to go back to school and pursue addiction counseling.

Later in life, I re-entered the world of mental health advocacy and behavioral health treatment. I have focused my efforts in working as a Mental Health First Aid instructor. I have specialized in behavioral health education — and whenever I talk about self-care, I mention the power of music.

Music Has Given Me Community And Support

As I have navigated life changes and mental health challenges, music has remained a constant. Twenty-seven years ago, I formed a small group of friends, and we began hosting what we called “Vinyl Night.” Together, we listened to records, shared stories of concerts we’d attended and recommended artists we loved. Vinyl Night has continued for decades, and it has become a support group for us, seeing us through births, deaths, life-threatening illnesses, job changes and moves.

I have also channeled my love for music into social media. Last year, I began sharing songs on Facebook and telling my own stories about music. A friend suggested that I create a podcast. At first, I was intimidated by the work required, but I found a contact who could help with the details. When we spoke, he mentioned that he was interested in taking on a mental health-related project. From there, we were able to launch a podcast with the help of the Buffalo NPR station.

Now, I Get To Talk About Music And Mental Health

On the podcast, I have conversations with my guests about the music that lifts their spirits — during difficult times and times of celebration. I’ve gone on to create a YouTube channel called “Mental Health Verses” to share more of this work.

I’m still amazed by how much joy this project brings me. It has allowed me to engage with what I am most passionate about while also raising awareness about mental health.

Karl Shallowhorn is the Director of Youth Programs for the Medical Health Association of Western New York and President and Founder of Shallowhorn Consulting, LLC. He is the Chair of Affiliate Relations for the Mental Health Association in New York State Board of Directors and was a speaker for TEDx Buffalo 2021.

Robert, an adult in his 50s, had been processing the early emotional neglect and abuse that led to his low self-esteem and a decade-long episode of depression. Together, we had processed his rage, fear and disgust.

With my therapeutic support and his courage, he worked his way through each emotion: Naming it, validating it, sensing it physically, and allowing it to flow up and out through his body. As the wave of each core emotion rose then fell, Robert experienced relief and newfound clarity.

The most surprising part of this process for Robert, however, was the deep sadness that spontaneously emerged alongside relief, lightness and growing confidence. In accelerated experiential dynamic psychotherapy (AEDP), we call this phenomenon “mourning for the self.”

Mourning for the self is healing in action. Fully feeling the core emotions that stemmed from his past traumas, Robert developed a profound understanding of how much he had suffered. With that acknowledgment came deep sadness for what he went through.

Finding Self-Compassion

Some people confuse mourning for the self with self-pity. Merriam-Webster defines self-pity as “a self-indulgent dwelling on one’s own sorrows or misfortunes.” That is not what mourning for the self is about. Self-pity stands in stark contrast to AEDP’s definition of mourning for the self which is “a painful but liberating experience of compassion for the self.”

Processing core emotions the way we do in AEDP requires a compassionate stance toward ourselves — a stance that many people have difficulty finding. When I first met Robert, he grappled with disdain for his inner child. When I coached him to approach himself with radical compassion and acceptance, he said things like “I hate that part of me for being weak, and I blame myself. I should have been able to escape.”

I asked him, “Would you ever blame your son if a teacher or relative mistreated him?”

He retorted with an emphatic, “No!”

“Why not?” I asked.

“Because he is innocent and just a helpless child. He deserves to be seen, loved and treated kindly.”

“Exactly,” I said, “You know how to be a good parent. Can you turn all that love and compassion inward to the little boy you once were?”

And then, an epiphany. He got it.

Mourning for the self is about not only understanding what we have been through but actually feeling those experiences for ourselves.

Finding Our True Selves

The consequences of unresolved traumas are huge. For many of us, years of our lives may have been compromised by false beliefs that we were not good enough or worthy of being loved. Beliefs that others could not possibly accept us for our true selves, flaws and all, can lead to loneliness and a feeling of disconnection. For many of us, unsatisfying relationships may have been the norm because we lacked trust in others. Some of us never had the pleasure of being in our bodies, feeling vital and authentic.

I love being an AEDP therapist because I see it as a healing model with predictable results. Over and over again, I have witnessed my patients process emotions and heal from their traumas. They recover their true selves. A key part of this process involves acknowledging losses and mourning.

Tears poured down Robert’s face as one hand covered his eyes in embarrassment. “I hate crying,” he said. Feeling deep love and admiration for this man, I gently whispered, “Your sadness is beautiful. It comes from your strength. This is your love… for yourself… and it’s good to let it come.”

Hilary Jacobs Hendel is author of the international award-winning book, “It’s Not Always Depression: Working the Change Triangle to Listen to the Body, Discover Core Emotions, and Connect to Your Authentic Self” (Random House). She received her B.A. in biochemistry from Wesleyan University and an MSW from Fordham University. She is a certified psychoanalyst and AEDP psychotherapist and supervisor. She has published articles in The New York Times, Time, NBC Think, FOX News and Oprah, and her blog is read worldwide. You can find free resources on emotions and the Change Triangle tool for emotional health at hilaryjacobshendel.com and follow her work on Facebook, Twitter, Instagram and YouTube.