What We Still Don’t Understand About Postpartum Psychosis

On August 1st, Lindsay Clancy, a labor-and-delivery nurse at Massachusetts General Hospital, posted to a Facebook group for followers of the “Miracle Morning” self-help regimen, which involves waking up early each day for meditation, visualization, and exercise. “Had my third baby 2 months ago and tried to stick with my MM after he was born,” Clancy wrote. In the previous couple of weeks, she’d fallen off track, but, she went on, “Even though I was up at 12:30, 1:30, and 3 with the baby I’m still gonna try starting my day at 5 so I can get a good MM in before everyone’s up. Wish me luck!!!”

In November, Clancy, who is thirty-two, posted to another Facebook group, called “I Am Not Alone: Postpartum Depression/Anxiety & Rage.” She disclosed that she was experiencing depression, insomnia, and decreased appetite while taking the antidepressant Zoloft; she fared better with Ativan, a benzodiazepine, but worried that she might become addicted to it. In December, Clancy wrote in her journal and confided in her husband about recurrent suicidal thoughts and, at least once, thoughts of harming her children. Just before Christmas, she was evaluated at the Women & Infants Hospital Center for Women’s Behavioral Health, in Providence, Rhode Island, where she was not diagnosed as having postpartum depression. (At some point, Clancy received a diagnosis of generalized anxiety disorder.) On New Year’s Day, she voluntarily checked in to the McLean psychiatric hospital, in Belmont, Massachusetts; she was discharged on January 5th, again seemingly without a postpartum-related diagnosis. Between October and January, according to reports, Clancy was prescribed at least twelve different medications.

On the morning of January 24th, Clancy brought her eldest child to the pediatrician for an appointment. Later that day, she built a snowman with two of her kids in the back yard of their home, in Duxbury, a suburb of Boston; she texted pictures to her husband. Toward dinnertime, Clancy called in a takeout order from a nearby restaurant. Her husband drove from their house to pick up the food and also stopped by CVS, at one point calling Clancy to double-check which brand of pediatric laxative she had asked him to purchase. He was gone for less than an hour. During that time, Clancy allegedly strangled her three children, ages five, three, and seven months, and then jumped from a top-floor window of the house, in an apparent suicide attempt. Clancy was arraigned on murder and assault charges from her Boston hospital bed on February 7th. Her attorney cited overmedication, postpartum depression, and the “possibility of postpartum psychosis” as potential mitigating factors in her defense. (Some of the details of the events leading up to and on January 24th have been drawn from attorneys’ statements during Clancy’s arraignment.)

The tragedy in Duxbury has drawn obsessive attention on Facebook, Reddit, TikTok, and elsewhere, sustained in part by Clancy’s digital footprint, which includes endless photos of Clancy and her children smiling at the zoo, smiling at the beach, smiling in the pool. Some observers have shared their hopes that the case will raise awareness of perinatal and postpartum mood and anxiety disorders, or PMADs, which affect perhaps one in seven people who give birth. One of those disorders, known as postpartum psychosis—what Clancy was possibly experiencing—is rare, affecting one or two in a thousand women, at a conservative estimate. Filicide driven by postpartum psychosis is rarer still: the risk is maybe four per cent, although estimates are shaky.

Postpartum psychosis tends to come on suddenly, often within four to six weeks of childbirth, around the time of weaning, or following a period of extreme sleep deprivation; it is sometimes presaged by anxiety and insomnia. A woman experiencing postpartum psychosis may show signs of mania, depression, or both; she may have aural hallucinations, paranoia, or delusions; she may stay awake day and night. She may, for stretches of time, appear to be perfectly normal.

During the arraignment, the prosecuting attorney stressed that Clancy did not receive a PMAD diagnosis when she was evaluated in Providence. But PMADs are significantly underdiagnosed, and often undertreated even when they have been recognized—one estimate is that only around three per cent of women with postpartum depression are treated to remission. The prosecutor also emphasized evidence of Clancy’s lucidity on the day of the killings: her voice did not sound “slurred or impaired” when she called the restaurant; when she texted her husband about her dinner order, she correctly spelled “Mediterranean Power Bowl.” On social media, where an initial sympathy for Clancy has been largely overtaken by condemnation, these details are deployed as proof that she was sane when she killed her children. But clarity of speech and behavior alone does not rule out postpartum psychosis. “One of the hallmarks is that there’s a waxing and waning of consciousness, confusion, and disorientation,” Lauren M. Osborne, the vice-chair of clinical research in the Department of Obstetrics and Gynecology at Weill Cornell Medicine, told me. “The result is that people with postpartum psychosis may appear fine at one moment and not fine the next moment. It’s that fluctuating course that’s very distinct.”

Although PMADs have an obvious triggering event, their neurochemical byways are not well mapped. Researchers suspect a link to the hormones estrogen and progesterone, which surge during pregnancy and plunge after childbirth. Postpartum psychosis is especially mysterious, although it disproportionately affects people with bipolar disorder. Clare Dolman, who is a postdoctoral researcher at King’s College London, received a bipolar diagnosis in early adulthood and took lithium to manage symptoms. She weaned off the drug before she became pregnant with her first child, with no adverse effects. “So I thought, I can breast-feed, because I’ve had nine months or more where I’ve been well,” she told me. Soon, though, she began experiencing mania and hallucinations; after a six-week hospitalization, she recovered. A year later, when Dolman decided to try for another baby, she had a plan: “I went back on lithium as soon as my son was born, I didn’t breast-feed, and I had no problems,” she said. For many women, however, postpartum psychosis is the first-ever presentation of bipolar traits; they lack what Dolman called “the experience and the insight to know that I was becoming ill.”

PMADs may also correlate with certain immunological deficits, preeclampsia and other inflammatory disorders, or gestational diabetes. But no one really knows. “Postpartum psychosis has been around for thousands of years, and yet it is not an official disease category in the DSM-5,” Veerle Bergink, the director of the Women’s Mental Health Program at Mount Sinai, told me. “There is no money for it, not for research, not for treatment. There are no guidelines. This is one of the most severe conditions in psychiatry, one that has huge impacts on the mother and potentially on the child, and there’s nothing.”

The presence of postpartum psychosis in medical literature reaches back to the Hippocratic Corpus, from the fifth or fourth centuries B.C., which described a new mother of twins who suffered delusions and sleeplessness. In “The Book of Margery Kempe,” which appeared at the turn of the fifteenth century and is believed to be the first autobiography written in English, Kempe, a Christian mystic, portrayed her postpartum loss of reason as having brought her closer to Christ. In Victorian England, it was believed that “puerperal mania” or “insanity of lactation” could cause new mothers to imagine harming their infants, or even to act upon these thoughts. The French psychiatrist Louis-Victor Marcé published the first substantive monograph on postpartum mental illness in 1858. “Where subjects are predisposed to mental illness through either hereditary antecedents, previous illnesses, or through an excessive nervous susceptibility,” he wrote, “pregnancy, delivery, and lactation can have disastrous repercussions.”

In the United Kingdom, owing to a law dating from the nineteen-twenties, a mother who kills her child generally receives a manslaughter charge leading to psychiatric treatment, in lieu of a murder conviction or prison time, if the baby is under the age of one and “the balance of her mind was disturbed by reason of her not having fully recovered from the effect of giving birth to the child or by reason of the effect of lactation.” Upward of two dozen other countries have similar statutes; the United States does not. Currently, Illinois is the only state that provides for postpartum mental illness as a mitigating factor in sentencing.

In roughly half of U.S. states, an insanity defense must conform to versions of the M’Naghten Rule, which originated in mid-nineteenth-century England. According to M’Naghten, a defendant must prove either that she didn’t know what she was doing when she committed a crime or that she didn’t know it was wrong. Michelle Oberman, a professor at the Santa Clara University School of Law, told me, “M’Naghten is a standard that doesn’t map onto most cases of maternal filicide” involving postpartum psychosis, owing to its waxing-and-waning cadence. “It’s difficult on a bunch of levels when someone is in and out of psychosis, because, when they’re ‘out,’ there’s a tendency to believe that they have the ability to control when they’re ‘in.’ It starts to look more volitional, and volition is one of the key components of M’Naghten.” Oberman went on, “The legal system is predicated on a binary of sanity/insanity.”

Judges and juries often locate volition even when it seems beyond question that a defendant is psychiatrically disturbed. Kimberlynn Bolaños, a woman in Chicago, killed her five-month-old son, in 2013, in the belief that she was saving him from being kidnapped and tortured; her insanity defense faltered in part because she admitted to feeling regret during the act. In 2015, a California woman named Carol Coronado was found guilty of first-degree murder in the stabbing deaths of her three daughters, ages two, sixteen months, and three months, even though three psychiatrists and a psychologist attested that Coronado was suffering from postpartum psychosis. Andrea Yates, perhaps the most famous American case of postpartum psychosis and filicide, drowned her five children in their home, in suburban Houston, in 2001; she was convicted of capital murder despite a documented history of postpartum psychosis, postpartum depression, and suicide attempts. Two facts were presented as evidence that Yates, per M’Naghten, comprehended that her actions were wrong: she waited—as Clancy did—for her husband to leave the house before killing the children, and she later called 911. (Yates’s conviction was eventually overturned.)