The Ones She Left Behind

Alexander Soukakos has his mother's deep brown eyes and heart-shaped chin. But he doesn't have the comfort of her arms, or the sound of her voice. At 16 months, he says Mama. But his mama never comes. He was asleep in the car, buckled in his safety seat, a year ago when Carol Soukakos hanged herself from a basement water pipe.

She had to work to die. On her first attempt, she tied a length of electrical wiring to a metal heating duct. The duct gave way and she crashed hard to the floor, gashing her head.

She must have been frantic. Her husband, a Seattle restaurateur, would be coming home soon. It was the first time she'd been left alone in weeks.

She tied the wire again. There was blood on her hands. The space was barely high enough to stand up in. To end her life, she had to bend her knees.

She left no note.

But she did leave, in retrospect, a chilling message.

Carol may have died by her own hand, but the noose around her neck was a severe form of postpartum depression, a widely underrecognized disorder that affects 10 percent to 20 percent of new mothers. In one or two cases out of 1,000, the depression becomes so extreme it verges into psychosis.

This is not the baby blues.

This is a stealthy, lethal invader that steals one of a woman's most primal urges: her maternal instincts. A lion will kill for its cub. Postpartum depression is the lion turned on itself.

A week before Christmas, Thomas Soukakos, 45, bustles around his kitchen, packing a bag for a babysitter.

Alexander chirps "cookie, cookie" from his highchair. Bright even in winter, the kitchen feels like the soul of this small, shingle-sided house nestled in the belly of Madison Valley. Toys and bottles litter the countertops where Thomas cooks for his son every day. Hand-written signs on the fridge tucked in among family photos say: "Stay present" and "Patience."

They're written in Carol's hand.

The first signs that something was going terribly wrong started just after Christmas a year ago.

Normally cheerful, compassionate and highly organized, Carol, 34, became increasingly confused and depressed. She was convinced she wasn't a good mother, that she wasn't producing enough milk, that she was failing her baby.

Sometimes she would grab her breast, squeeze hard, and say, "See?" She would look at Thomas wildly when nothing came out.

Sari Gallegos, the naturopathic doctor who delivered Alexander, assured her the baby was thriving. Thomas assured her she was a good mother.

But Carol couldn't be convinced.

"Why she thinks all those things I have no idea," he would say later.

Thomas, who came to the States from Greece 18 years ago, is an earnest, passionate man. Sometimes, when he talks, he clutches at his heart, as though trying to rip the right words from it. He has something to say. He wants people to listen. He wants them to understand about postpartum depression and psychosis so no other child will lose his mother. He doesn't want them to look away.

She Could Do Anything

Thomas was engaged to someone else the day Carol, a pretty, down-to-earth woman with a soulful laugh, walked into El Greco, his cozy Capitol Hill restaurant, to apply for the pastry chef's job.

Carol, a native of Syracuse, N.Y., had graduated from the New England Culinary Academy, eventually making her way to Seattle in 1990.

"My biggest fear was I would die without feeling really in love," Thomas said. "Boom, she walked in, and I recognized it."

He handed her the job that day. And his heart.

They married three years later. Her "maid of honor" was her best friend from culinary school, Jim Goodall.

"We were on top of the world. We had everything for 5 1/2 years," said Thomas. They bought a house together, and she indulged her passion for gardening and yoga. They traveled together: Greece, Paris, Canada, California. They cooked together. Their customers became friends, and their friends, customers as their restaurant became an extension of their living room.

"It was like a family there," said Misha Whitfield, who worked at the restaurant and became one of Carol's closest friends.

Carol and Thomas tried to conceive for several years. On New Year's Eve 2000, they found out she was pregnant.

She was so excited, she called Goodall, who was in Paris, to tell him. It was midnight across the ocean, and as Carol shared the news of Alexander's nascent presence, fireworks lit the sky.

Alexander arrived Sept. 4, three days after their fifth anniversary. He was a breech birth, but she gritted out the pain. She didn't want a Cesarean. "She was very courageous," Thomas said. "I was so proud of her. She was a strong lady."

At first, Carol appeared to handle motherhood the way she handled the rest of her life.

"She was very passionate about everything she did," said Whitfield. "She was so strong-willed; she could do anything."

Then at four months, her outlook suddenly changed. Carol described it as a "veil coming down over her head."

Over the next few weeks, Carol became increasingly distraught. In the last weeks of her life, she was visiting Gallegos, who was also Alexander's doctor, nearly daily, looking for support. One time, she showed up at 9 a.m. for a 5 p.m. appointment. She stayed most of that day in the waiting room.

She told her husband she went there to feel safe. She was having disturbing thoughts.

On Jan. 4, 2001, her doctor's handwritten notes say Carol "worries b/c feels Tomas (sic) and Alexander would be better off without her — i.e. `bad thoughts in her head.' Carol says she would never/could never kill herself b/c she could not do that to her husband and her son. She denies a plan." The doctor also noted that Carol brought up having gone through depression years earlier and worried that things would get "out of control."

She went home and told her husband "I'm losing my mind." That night, he stayed up to watch her. "She stared at the ceiling the whole night," he said. He brought the baby to her, and although she let him breast-feed, she wouldn't cradle him in her arms.

In desperation, Thomas called the midwife. It was 5 a.m. Gallegos said she reassured him that although Carol should be seen by specialists, she would be OK. Thomas remembers being told not to worry; women go through this all the time.

Many Women Hide Symptoms

Postpartum mood disorders are common, but usually not extreme. Experts say about 80 percent of new mothers experience feelings of anxiety and sadness, commonly known as the baby blues, in the first two weeks after birth.

Postpartum depression is more severe and can appear anytime in the first year. Mothers may have difficulty sleeping, despite exhaustion. They may feel detached from their child and guilty because of it. They may have trouble coping, and struggle with feelings of isolation and inadequacy.

Many feel deeply ashamed.

"We are told that pregnancy and childbirth should be the happiest time of your life, but that's a cultural myth," said Diana Lynn Barnes, a clinical psychologist and specialist in postpartum mood disorders in Woodland Hills, Calif. "It's a very tumultuous time in the life of a woman, and one of the most stressful periods in her life. It's a developmental crisis and needs to be treated as such."

As a result, women tend to hide or minimize their symptoms. When they do bring them up, doctors and others sometimes make things worse by dismissing them as normal adjustment problems.

Women with histories of depression or mood disorders, and those who have had trouble with severe premenstrual syndrome symptoms — both of which Carol had — also appear to be more vulnerable to postpartum depression.

Postpartum psychosis is much rarer, and more typically happens soon after delivery, although a depression can also escalate into a full-blown delusional mindset, experts said.

Although researchers don't fully understand the brain chemistry of postpartum depression, many believe it to be biologically based and triggered in part by the massive drop in hormones that occurs after delivery.

Once the placenta is delivered, the levels of estrogen and progesterone drop precipitously. By one week out, levels of progesterone drop from 20 to 30 times their pre-pregnancy levels to next to nothing. The level of estrogen plunges to less than 1 percent of its pregnancy level.

These hormones act in part on the limbic system, the part of the brain that governs our most basic drives — appetite, sex, aggression, memory and the menstrual cycle — essentially the functions that sustain and protect life. Disrupting the regulation of these functions can prove deadly. About 5 percent of patients with postpartum psychosis kill themselves. About 4 percent kill their babies, a phenomenon that some believe drove Andrea Yates to drown her five children in June 2001.

No one knows how many patients with diagnosed postpartum depression, but not psychosis, also kill themselves.

Screening Test a Cry for Help

Despite Gallegos' assurances, Thomas felt uneasy. "My wife was in a fog," he said.

He called Goodall in Paris, but Carol refused to talk to him - her oldest and best friend. That was the first time Thomas got really scared.

Goodall was scared as well. Too late, he had picked up a message Carol had left on his Seattle answering machine a few days earlier. "She was quite distressed, in a fairly bad state," he said.

He told Thomas to get her to a psychiatrist. Thomas called medical centers asking to see a psychiatrist, but it was the weekend and none were immediately available. Several frantic hours later, he was referred to Fairfax Hospital, a psychiatric facility in Kirkland.

On the way to the hospital, she told him she was thinking about walking into the lake, or jumping from a balcony, but that she would never do that to him. He believed her.

"I trusted my wife," he said. "We had the strongest, unconditional love you can imagine."

The hospital evaluated her and consulted with the psychiatrist she'd seen many years earlier for depression and anxiety. They gave her the choice of checking into the hospital for treatment, or going home and seeing a psychiatrist the next day.

She wanted to go home. They cooked dinner together that night and she seemed better.

On the hospital's recommendation, they made arrangements for her to visit family in New York. They contacted a doula, a woman trained to help mothers through labor and the transition to motherhood, to come in a few days a week to give Carol some support. The doula put them in touch with a social worker and psychiatric nurse-practitioner.

A week later, Jan. 14, Carol saw the social worker who gave Carol a standard postpartum depression screening test with 36 statements. Carol had to indicate how she felt about each of them:

"Did not know who I was anymore."

She marked a 5, meaning "strongly agree."

"Felt like a failure as a mother."

Strongly agree.

"Started thinking that I would be better off dead."

Strongly agree.

Three times, in three different ways, the test probed for suicidal thoughts. Each time, she marked a 5.

Thomas never saw the test, or her scores. He was never told their implications.

"Nobody said anything to me except go home, this is normal," he said. "They said, `Yeah, everything's going to be fine.'"

The next day, they went together to see the nurse-practitioner. They left with a sample of Zoloft, an anti-depressant, and a prescription for more.

On the way home, Carol told Thomas he should take a little break to get some paperwork done at the restaurant. She dropped him off at 1 p.m. Forty-five minutes later, she was dead.

He found her hanging when he came home.

Support From Church, Friends

"It was a death for me," he said. "It's like I died."

Thomas sits at his dining room table on a gray January day as the horrible, inevitable anniversary of her death approaches. The table, where they once shared meals, now doubles as a desk. He shuffles through reports and articles, information he's gathered about postpartum depression, trying to make sense of the unthinkable. He rubs freckled hands over his face, and through a stubby crop of graying hair. His auburn eyes are tired.

Since her death, Thomas' friends and neighbors have wrapped their collective arms around him and the boy. There is always someone to watch Alexander, to take him to the park. Neighbors gave Thomas a jogging stroller for his first Father's Day. They bring food. They've set up a trust fund for the baby.

Alexander wants for nothing, except a mother.

The milestones tick away. In the summer, Thomas took him to Greece to be baptized.

His first word was "book."

A few weeks ago, he had his first haircut. Then came the first steps.

Thomas has sold the restaurant. The 80-hour weeks were too much, and it wasn't the same without his wife.

Now he's trying to start a new business where he can make a schedule that lets him be with his son. Perhaps a small cafe that serves just breakfast and lunch, or a catering service.

"I'm a strong believer everything happens for a good reason," he said. "I just don't know how I'm right."

He goes to St. Demetrios Greek Orthodox Church when he needs solace, especially on the anniversary each month of the day she killed herself. When things get really bad, he goes every day.

"Sometimes it is like my spirit is suffocating," he said. "How much I miss my wife — like a guillotine, it snaps down on me. Then it takes a conscious effort to open my eyes up and see the good things."

He sees Alexander.

A Quest to Save Others

Alexander has awakened from a nap, and is exercising his next favorite word after "cookie."

"Do you want your elephant?" Thomas' voice is steady, bemused.

"No!"

Do you want something to eat? No! Thomas buckles his son's squirming body into the highchair and smoothly starts the lunch ritual.

"How about this? Look at this!" The kitchen fills with the warm smell of buttered toast.

No! No! No! But Alexander reaches for it, and begins to eat despite himself.

Thomas laughs. Lunchtime is for chatter. In the mornings, he and Alexander "hang out like the boys."

Thomas reserves his patience for his son.

In the rest of his life, he is less patient. He wants to see changes. He wants more education for fathers, so they can better recognize mothers suffering from postpartum depression. He wants caregivers to be more alert to those most at risk. He wants insurance companies to better cover care for it.

In his grief, he has found a mission. "It's like searching your soul. You go to the deepest place to find out who you are. What is my purpose?"

He spends much of his energy trying to educate all those involved in the care of pregnant women and new mothers about the risk of depression.

Last June, he went to Santa Barbara, Calif., to the Postpartum Support International meeting. The people who devised the screening test his wife took were there. They said if a woman scored 120 to 130 on the test, caregivers should take "extreme measures" to intervene. Carol's score was 151.

The focus of the session was on training people how to give the test. Thomas, filled with emotion, found himself suddenly on his feet.

"What's important is not to give the test, but to pay attention to it," he told them. "You expect a woman to put a lifetime on a piece of paper, yet if you're not going to pay attention. ..."

Carol could have been immediately hospitalized or sedated in the caregiver's office so she could rest, then be observed. She shouldn't have been left alone. Even for a minute.

He talks to anyone who will listen. "Maybe they will learn something from me," he said.

We Could Have Caught This

Some people are listening.

In California, mental health advocates are working to get legislation to mandate depression screening for pregnant women so that a support plan is in place when the baby is born. In Illinois, where four women committed suicide in summer 2001, a governor's task force is developing guidelines for identifying and treating postpartum mood disorders.

U.S. Sen. Richard Durbin, D-Ill., has introduced the Melanie Stokes Bill, named for a Chicago woman who jumped from a 12-story hotel window, that would provide for more research on, and better services for, postpartum depression and psychosis.

In the meantime, those who cared for Carol are left with "what-ifs." Carol saw at least a half-dozen people who tried to help her in the last weeks of her life, from a "spiritual therapist" to a psychiatrist. None seemed able to shake her delusion that her family would be better off without her.

At the time, each thought the right things were getting done. Gallegos, who cared for her the longest, is still tormented by how her death might have been prevented. "It was so fast-moving," she said. "It literally felt like trying to stop a charging bull."

Abby Myers, the nurse-practitioner who saw Carol for the first time the day she died, said early intervention is critical in treating depression. Myers, who heads Depression After Delivery, a postpartum support group, said lack of awareness about postpartum depression contributed to Carol's death. "We need to educate all different kinds of providers about this," she said.

And parents as well.

Myers said Washington should copy New York's law mandating that women be informed in the maternity ward before they are discharged about what signs to look for and how to get help.

Gallegos has her regrets. "What I do wish is maybe if we had all talked more — all of us, and Thomas — that maybe then we could have caught this."

If there's a lesson, it's that denial can be deadly.

"As health care providers we have to deal with our own sense of belief that it couldn't happen," she said. "The part we all missed, we thought no matter how difficult it was, she would never leave her son."

Thomas believes his wife didn't really want to kill herself, that she was not in her right mind.

Almost to himself, he said: "I forgive her."

When Alexander looks at her picture and asks for her, he tells him she's watching them. He isn't sure yet what he'll tell him in the future.

But he doesn't flinch recounting details of her death to others, and he will tell them again and again if it will make a difference. He wants people to understand how desperate she was.

"I'm like Sisyphus," he said. "I will push that huge ball up the hill over and over to prevent it from happening one more time."

2004 Dart Award Final Judges

David T. Cullen is a free-lance journalist. He has contributed work to The New York Times, National Public Radio and the online publications Salon.com and Slate.com. Cullen covered the school shootings in Littleton, Colorado, as well as the trials of the murderers of Matthew Shepard in Laramie, Wyoming. A former lieutenant in the U.S. Army, he taught creative writing at the University of Colorado in the mid-1990s, and was a Dart Fellow in 2002. Cullen is the recipient of a GLAAD Media Award, a Society of Professional Journalists Award and several Best of Salon Awards.

Michelle Guido is the Women’s Issues reporter on the Race and Demographics team at the San Jose Mercury News. In her 14 years at the paper, she has covered education, city and county government, police, courts and youth issues. She spent 1999 reporting on domestic violence, and revisited the issue in 2002 with a first-person piece after her friend, Mercury News photographer Luci Williams Houston, was murdered by her husband. Guido has taught journalism classes at San Francisco State University and helps run Mosaic, a summer urban journalism program for minority high school students. Her national awards include a 2002 Associated Press News Executives Council Award for “A Victim’s Hidden Struggle”; an EdPress National Award for Excellence for both features and breaking news in 1992; and a (team) Pulitzer Prize for spot news coverage of the 1989 Loma Prieta Earthquake.

Saed Hindash is a photojournalist at the Star-Ledger, New Jersey’s largest newspaper. In 2002 he won the Dart Award, along with reporter Matt Reilly, for a story about a Siberian orphan who was beaten and froze to death in the custody of his adoptive parents in central New Jersey. Before joining the Star-Ledger, Hindash worked for newspapers in Cincinnati, Pittsburgh, and in Everett, WA.

Lori S. Robinson is the author of I Will Survive: The African-American Guide to Healing from Sexual Assault and Abuse (2003). She is a freelance journalist whose work has appeared in the Washington Post, Essence, The Crisis and The Source, among other publications. Robinson lectures and conducts workshops around the country on sexual violence. She recently taught media at Universidad San Francisco de Quito in Ecuador. A former editor at Emerge: Black America’s Newsmagazine, her honors include National Association of Black Journalists awards, Unity Award in Media prizes, and the International Black Women’s Congress Inspirational Award. Robinson earned a master’s degree in journalism from New York University in 1994.

Barbara Rothbaum is president-elect of the International Society of Traumatic Stress Studies (ISTSS) and associate editor of The Journal of Traumatic Stress. She is currently a tenured associate professor in psychiatry at the Emory School of Medicine in the Department of Psychiatry and Behavioral Sciences and director of the Trauma and Anxiety Recovery Program at Emory. She has won both state and national awards for her research. She writes scientific papers and chapters and has published two books on the treatment of PTSD. She received the Diplomate in Behavioral Psychology from the American Board of Professional Psychology. Dr. Rothbaum is also a pioneer in the application of virtual reality to the treatment of psychological disorders.