Postpartum Psychosis on Trial: What the Lindsay Clancy Case Can Teach Us

CLINICAL CONVERSATIONS

The murder trial of Lindsay Clancy, a former labor and delivery nurse charged with killing her 3 young children in Duxbury, Massachusetts, in January 2023, has renewed national attention on postpartum psychosis and how the condition is understood in both clinical and legal settings. Clancy has pleaded not guilty to first-degree murder in the strangulation deaths of 5-year-old Cora, 3-year-old Dawson, and 8-month-old Callan. Her defense has argued she was experiencing severe postpartum psychosis and taking multiple psychiatric medications at the time of the killings.

As testimony continues, the case has prompted broader public questions about how postpartum psychosis develops, why it can escalate so quickly and unpredictably, and how forensic psychiatrists evaluate maternal mental illness in the context of a criminal trial.

To help clinicians make sense of these questions, Psychiatric Times spoke with Susan Hatters Friedman, MD, MSt, DFAPA, the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University School of Medicine, where she also holds appointments in pediatrics and reproductive biology.

Psychiatric Times: The Lindsay Clancy case has drawn the issue of postpartum psychosis back into the news, and with it a lot of stigmatizing language, such as “murder vs madness.” Do you think coverage of postpartum psychosis, in this light, perpetuates misunderstanding of the condition?

Susan Hatters Friedman, MD, MSt, DFAPA: Historically, the public has had very little understanding of postpartum psychosis. So with the media’s focus on this tragic case, there has been an opportunity for more community education about postpartum psychosis—which is critically important. There has been some great educational media coverage.

But, yes, the media is focusing on postpartum psychosis now because of the defense attorney’s statements that Lindsay Clancy had postpartum psychosis at the time of killing her children. Often the media focuses on stories about mental health when violence is involved. And the public often conflate mental illness and violence. It is important that the message that the public gets about postpartum psychosis is about identification and treatment, not merely risk. If the message is only about risk, we worry about women who are experiencing symptoms not seeking treatment because of stigma and because of fears of losing custody of their kids.

PT: The recent news has also pulled the issues of identification and pharmacological management of postpartum psychosis into focus. What tips would you offer your fellow clinicians in terms of identifying and managing postpartum psychosis?

Hatters Friedman: Postpartum psychosis needs to be on our radars when we are evaluating new moms with mental health concerns. Postpartum psychosis includes not only psychotic symptoms, but also dysphoric mania, and confusion. It typically presents fulminantly, in the weeks after delivery, with symptoms that wax and wane. Medical as well as psychiatric evaluation is important for postpartum psychosis, as a medical complication of delivery could present similarly to postpartum psychosis and require very different treatment.

Postpartum psychosis is typically a psychiatric emergency. Moms with postpartum psychosis usually initially require psychiatric hospitalization for acute treatment. If there is an outpatient mom who you are sending to the emergency department for medical evaluation, calling to provide collateral information can be critical—especially due to the waxing and waning nature of symptoms and the powerful reasons for a mother to seek to minimize her symptoms.

In the differential diagnosis, postpartum OCD is something we see more frequently than postpartum psychosis. In evaluating moms, it is important to carefully consider whether thoughts are obsessive intrusive thoughts, or whether a mother is experiencing psychosis—and out of touch with reality.

PT: How would you say treatment of postpartum psychosis differs from treatment of schizophrenia/psychosis?

Hatters Friedman: The treatment is different in many ways. One, postpartum psychosis has a rapid onset as compared with schizophrenia, and initial treatment almost always needs to be inpatient. Two, postpartum psychosis does not only present with psychotic symptoms but also confusion and dysphoric mania, so medication choices reflect that. Three, our risk assessments for postpartum psychosis need to keep in mind the elevated risks of both suicide and infanticide, as well as practical difficulties with caring for the infant due to symptomatology. Fourth, after the mother gets better, our treatment plan will differ depending on her underlying diagnosis if any, and for prevention in future pregnancies.

PT: What psychopharmacological options are available? Is there one you prefer?

Hatters Friedman: Lithium’s efficacy in postpartum psychosis is well established. Antipsychotic agents, especially second generation, and benzodiazepines are often used adjunctively. Electroconvulsive therapy is also an option. Treatment with an atypical antipsychotic agent such as olanzapine, which can target both mood symptoms and psychotic symptoms, might be preferable to some mothers. But as always, we should consider her individual symptoms, their severity, any past medications, adverse effect profiles, and, depending on the circumstances, safety in lactation.

PT: Personal history of bipolar disorder or a family history of postpartum psychosis are known to elevate the risk of developing postpartum psychosis. Are there any other risk factors worth noting?

Hatters Friedman: Her own personal history of bipolar disorder increases the risk strongly—up to 100x higher than the general population. Her history of postpartum psychosis after a previous pregnancy is a major risk factor too, as is a family history of postpartum psychosis. Other risk factors are being studied but do not increase the risk nearly as much as these.

PT: Patrick Clancy testified in the ongoing trial: "I didn't know what psychosis was until after this happened.” I imagine this might be the case for many mothers to be/their partners. How can clinicians help improve awareness of this issue? How can we incorporate these conversations into care during, or even before, pregnancy?

Hatters Friedman: Absolutely, there is a lack of good mental health understanding for many people in the general population. Think about what any of us knew about mental health after our high school health classes, and contrast that with the information we want our patients and their families to know about mental illness.

Education about postpartum mental illness is important not only for psychiatrists to provide (after someone has been identified to have a mental health issue), but also for both obstetrics and pediatrics. The Edinburgh Postnatal Depression Scale (EPDS) has been used for decades to help identify moms with postpartum depression (as well as depression in pregnancy). Obstetricians’ offices screen for depression, and importantly, pediatricians also use the EPDS to screen. Imagine the stressed mother experiencing depression: she might not attend her 6-week obstetric follow-up but will still bring her baby in for the many pediatric visits in the first year of life, when that mother herself is most at risk for mental health issues.

Obstetricians (and psychiatrists when they are involved) should educate moms-to-be about the importance of sleep (when possible) and of getting help in the postpartum when needed. Postpartum depression, anxiety, and psychosis can all be discussed during pregnancy, as mental health risks in the postpartum are among the most important postpartum risks. And then responsive psychiatric services need to be in place for mental health referrals. Moms can also be warned of what symptoms would necessitate a crisis center call or an emergency department visit.

PT: Postpartum psychosis is currently not included in the DSM, but as we know, a new DSM is on the way. What argument would you make for postpartum psychosis to be included?

Hatters Friedman: Postpartum psychosis has been described since the time of Hippocrates, yet is not in the DSM. Research also demonstrates strong heritability and genetic links. Without appearing in the DSM, trainees in psychiatry and other medical disciplines may not spend time learning about postpartum psychosis. (There are so many disorders for people to learn about that are in the DSM.) This then leads to a lack of community education, lack of identification of postpartum psychosis in vulnerable mothers and families, and lack of appropriate treatment. Research is limited for diagnoses that are not considered worthy of DSM inclusion. Finally, as a forensic and reproductive psychiatrist—when a tragedy does occur, and the mother does have postpartum psychosis (such as Andrea Yates did), explaining to the court about a mental illness that is not listed in the DSM when the courts are used to us proffering DSM diagnoses, is problematic.

Dr Hatters Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry; professor of psychiatry, reproductive biology, and pediatrics; and adjunct professor of law at Case Western Reserve University in Cleveland, Ohio. She served as editor of the Group for the Advancement of Psychiatry volume Family Murder: Pathologies of Love and Hate, which won the Manfred S. Guttmacher Award.