The recent news cycle has focused on the tragic deaths of three young children in Boston, allegedly at the hands of their mother. Lindsay Clancy, a labor and delivery nurse, has been charged with homicide in the killings of her 8-month-old, 3-year-old, and 5-year-old children. It is believed that after she strangled them, she injured herself, then jumped from her home’s second story window. At present, we don’t know what mental health diagnosis she merits. Various sources have suggested that Clancy was suffering from postpartum psychosis at the time. This harkens back to 2 decades ago and the tragic case of Andrea Yates, who had been diagnosed with postpartum psychosis long before she murdered her five young children.
The postpartum is romanticized as the perfect time of bonding with a new baby. But the reality is that for many new mothers, it is a difficult time, with a new role with new responsibilities, limited opportunities to sleep, and hormonal shifts. Each of these — along with a family or personal mental health history — can increase the risk of postpartum mental illness.
What Is Postpartum Psychosis?
Postpartum psychosis is one of the most concerning of psychiatric disorders. Fortunately, it is rare, occurring in 1-2 per 1,000 mothers. It can present in an otherwise healthy young woman with no history of mental illness, whose very young infant is completely dependent upon her. It often presents in the first 2 weeks postpartum, after she has left the labour and delivery unit. New mothers develop symptoms not just of psychosis but also of mood disorders and delirium-type symptoms. Their presentation may appear as a fulminant psychosis, with rapid-onset hallucinations (commonly hearing voices or seeing visions) and delusions (tightly held false beliefs), mood swings, and confusion as well. It also develops much more quickly than the delusions of schizophrenia, and changes over time, fluctuating rapidly with periods of lucidity. The absence of postpartum psychosis in the DSM, despite it having been described since the time of Hippocrates, causes difficulties both in making the diagnosis in the emergency room and in forensic cases after infanticides (murders of infants).
Postpartum psychosis is not postpartum depression.
Mothers with postpartum depression need identification and treatment too — but their illness is not the same. Postpartum depression screening is effective and simple using the Edinburgh Postnatal Depression Scale, freely available online. Postpartum depression occurs in about one in five mothers, who present with signs of depression in the postpartum. Untreated, severe depression can lead to psychotic symptoms, but the progression and treatment is different than in postpartum psychosis.
Postpartum psychosis is not postpartum obsessive-compulsive disorder (OCD). Postpartum OCD, which commonly occurs with postpartum depression, is instead on the spectrum of anxiety disorders. Mothers with postpartum OCD have obsessive distressing thoughts that may focus on their infant’s safety. But they are fears or worries about harming their infant, which they experience as ego-dystonic and distressing. These are fears, not plans.
Furthermore, mothers experiencing symptoms of postpartum psychosis are likely to experience fear of what is happening to them, and internalised stigmatisation about mental health especially in the postpartum, as well as worries about losing custody of their child. They may appear asymptomatic during a brief ER visit. For example, a mother sent from the pediatrics ward to the emergency department due to concerns of risky behaviour upstairs, may act appropriately during a 15-minute interview. This is why collateral information can be so important in making an accurate diagnosis, getting proper treatment, and prevention of risk.
We must be careful not to conflate postpartum psychosis with infanticide. Not all infanticides are due to mental illness — despite common misconceptions. However, postpartum psychosis is well-known to increase the risk of infanticide. Approximately 4% of cases of untreated postpartum psychosis end in child murder. Similarly, suicide risk is elevated in untreated postpartum psychosis. And mothers who are psychotic have a difficult time focusing on the needs — even hunger — of their vulnerable infants.
Interventions for Postpartum Psychosis
Put simply, postpartum psychosis is a psychiatric emergency, and the vast majority of these mothers require psychiatric hospitalization for safety and treatment. Postpartum psychosis is treatable in the psychiatric hospital. Mood stabilizing and antipsychotic medications may be used. The mother’s support system is engaged in the treatment and safety planning.
In recent decades, huge strides have been made in educating the community about postpartum depression. However, community knowledge lags behind about this rare yet even more dangerous condition. Moms are more likely to go to pediatricians’ offices than to their own healthcare provider after their babies are born, and pediatricians play an important role in identification of maternal mental health concerns too. Educating mothers — and their support system — about postpartum psychosis, and educating ourselves as physicians about what to look for is critical in the diagnosis and treatment of postpartum psychosis.
Susan Hatters Friedman, MD, is the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, where she is also Professor of Psychiatry, Reproductive Biology, Pediatrics, and Law (Adj).