Postpartum psychosis: Why do we only pay attention after a tragedy?

The trial of Lindsay Clancy, charged with the murder of her three children, ended without a verdict on September 4. After seven days of deliberation, 11 jurors were on one side and one juror was on the other, and the judge declared a mistrial. The Plymouth County district attorney has not yet said whether he will retry the case (1,2).

Throughout the trial, the psychiatric evidence was disputed (1). This article is not an attempt to reach a conclusion the jury could not.

But the public response tells us something important.

Alongside horror at the death of three children, there has been an outpouring of compassion for the woman charged with killing them. To some people, that compassion appears misplaced, as though acknowledging the possibility of severe mental illness diminishes the lives that were lost. For others, particularly mothers, the case has struck a different nerve. They see a woman becoming increasingly unwell after childbirth who, despite several contacts with healthcare services, did not get the help she needed.

We do not have to decide which account of this individual case is true to examine why it struck such a nerve. 

We treat motherhood as the strongest and most instinctive form of love there is. So when a mother harms her children, the public quickly reaches for moral explanations. She must be cruel, selfish, or even calculating. A monster. Postpartum psychosis introduces a far more difficult possibility: that a person can love her children and, during a severe psychiatric illness, lose the ability to understand reality. 

This is what psychosis does. It is not a verdict, and it does not make the harm any smaller. But our unwillingness to hold those two ideas at once is part of why postpartum psychosis stays so badly understood.

Right now there is a lot of discussion about what should happen after a tragedy of this kind has occurred. But the real question is a public health one: why does a rare yet treatable psychiatric emergency still tend to become visible only after something catastrophic has already happened?

Postpartum psychosis is not an extreme version of the baby blues

Postpartum psychosis is a rare but severe mental illness that develops after childbirth. Symptoms may include delusions, hallucinations, mania, severe depression, paranoia, confusion, or behavior that is dramatically out of character (3,4). A delusion is a strongly held belief that is not based in reality. Someone might believe that they or their baby have special powers, that people are trying to harm them, or that they are receiving messages or instructions from an outside force. Hallucinations are when a person hears, sees, smells, or feels things that are not there.

But postpartum psychosis often doesn't look the way people expect psychosis to look. Most cases are dominated by mood symptoms. In the largest study of how postpartum psychosis presents, 130 women had manic (34%), depressive (41%), and atypical, delirium-like (25%) presentations (3). Early warning signs can include severe insomnia, increased energy, racing thoughts, restlessness, irritability, and extreme mood swings (3). Symptoms can also change very quickly, sometimes within hours, which is one reason it often goes unnoticed (3). A woman can be acutely unwell at three in the morning and composed and articulate by the time someone sees her at ten (3).

Postpartum psychosis typically develops within the first two weeks after birth, often within only a few days. It can develop later, but this is less common (3,4). Because of its rapid development and the person affected’s lack of insight into their state, postpartum psychosis is regarded as a psychiatric emergency that needs to be treated quickly (4). This loss of insight matters. We tell people experiencing mental health problems to ask for help. That advice collapses when one feature of the illness is being unable to recognize that help is needed. Partners, relatives, friends, and healthcare professionals must be prepared to act on their behalf. What often gets lost in the coverage is that most women with postpartum psychosis do not harm anyone. When the illness does end in death, it is more often the mother who dies (5). In the United States, mental health-related illnesses are killing more women within the year after childbirth than hemorrhage or heart disease combined. Most of these deaths are thought to be preventable (6,7).

Hormones may be part of the picture, but they are not the whole explanation

There is no single known cause of postpartum psychosis. Childbirth causes abrupt changes in reproductive hormones, as well as changes to the immune system, sleep, stress, and the body's internal clock. Researchers believe these changes act as a biological trigger in people who are already vulnerable (5). 

But you cannot reduce this to hormones. Hormones change after every birth, while postpartum psychosis affects approximately one to two people in every 1,000 (4,8). Genetics, a personal or family history of severe mental illness, medication changes, complications during childbirth, and severe sleep disruption may all play a part  (5,8,9). Some people are at greater risk of developing postpartum psychosis than others. People with bipolar I disorder, schizoaffective disorder, or a previous episode of postpartum psychosis are all at increased risk. Women with bipolar disorder have a risk of a postpartum episode of around one in six, with one meta-analysis putting it as high as one in five (5,8). For women who have had a previous episode of postpartum psychosis, the risk of recurrence after a subsequent birth is roughly one in three (5,10). A family history of postpartum psychosis or of bipolar disorder also increases the risk, as does a first pregnancy (10,11). People known to be at higher risk should ideally receive perinatal mental healthcare during pregnancy. This can include a written plan covering medication, sleep-management strategies, early warning signs of mental illness, emergency contact details, and what should happen immediately after birth. In much of the country, finding that specialist is the hard part. But postpartum psychosis can also occur in someone with no previous psychiatric history at all. This is not a rare exception. About half of the women who develop it have no prior diagnosis of serious mental illness (12). For these families, the first sign of vulnerability is the episode itself. This emphasizes the importance of perinatal mental health screening for everyone, along with access to appropriate resources. A system that only screens for known risk factors will miss roughly half of the people it needs to find.

The earliest warning signs may not look like psychosis

Postpartum psychosis can be easily mistaken for exhaustion, anxiety, or the emotional upheaval that comes with caring for a newborn. What sets it apart is usually the speed, intensity, and unusual nature of the change (3). 

Early warning signs can include:

• Being unable to sleep, even when the baby is asleep, or someone else is caring for the baby

• Feeling unusually energetic, or as though sleep is unnecessary

• Racing thoughts or talking much faster than usual

• Severe agitation, restlessness, or irritability

• Rapid, extreme mood swings

• Confusion or trouble following a conversation

• Paranoia or intense suspicion

• Feeling watched, controlled, persecuted, or specially chosen

• Beliefs that seem impossible or disconnected from reality

• Seeing or hearing things other people do not

• Behavior that is dramatically out of character (3,4)

Sleep is particularly complicated. A new parent being repeatedly woken up by their baby is different from someone who is unable to sleep even when given the opportunity, or who suddenly feels no need for sleep at all. Sleep loss can increase vulnerability to mania or psychosis, and being unable to sleep can also be an early symptom that an episode has already begun (8).

Partners and family members may notice these changes before the person experiencing them does. A sudden sense that someone is profoundly “not themselves” should be taken seriously, particularly during the first weeks after birth. Yet we currently rely heavily on new parents and families to recognize when a condition exists that most have never even heard of before.

Not every frightening thought is psychosis

The intense media coverage of rare tragedies can frighten people who are experiencing much more common postpartum mental health symptoms. Precision matters here, and so does scale. Baby blues affect somewhere between half and four-fifths of new mothers. Postpartum depression affects roughly one in eight (13). Postpartum psychosis affects one or two in a thousand (4,8). Baby blues can cause tearfulness, irritability, anxiety, and mood swings during the first days after birth, typically peaking around day three to five. They usually settle within two weeks and do not involve losing touch with reality (13,14).

Postpartum depression is characterized by persistent low mood and can include loss of interest, hopelessness, guilt, changes in sleep or appetite, and thoughts of death or self-harm. It can be severe and require treatment, but most people with postpartum depression stay connected to reality. In rare cases, severe depression can occur with psychotic features, which is a different and more serious presentation (3).

Postpartum obsessive-compulsive disorder can involve frightening and intrusive thoughts or images of harm coming to the baby. These thoughts are usually deeply distressing and conflict with what the person wants. They cause anxiety precisely because the person is horrified by them. Having an intrusive thought does not mean someone wants to act on it, nor does it predict harm.

A psychotic belief is different. It is not experienced as an unwanted thought but as something true. In fact, most postpartum psychosis involves no thoughts of harming anyone at all. In rare cases, a delusion may make harm seem justified. The risk of infanticide in untreated postpartum psychosis is estimated to be between 1% and 4% (8). It is this rare and severe form of postpartum psychosis that dominates media coverage and distorts public understanding of the illness as a whole. 

People should be able to talk about intrusive thoughts that are worrying them without fear of being treated as if they are dangerous. Only a qualified healthcare professional can determine what symptoms mean in an individual situation. Putting every postpartum mental health problem into the same frightening category increases stigma. It also makes people less willing to say what they are experiencing out loud.

The tragedy is that postpartum psychosis is treatable

Postpartum psychosis is severe, but it is treatable, and many people recover fully. The long-term prognosis is good when the illness is identified and treated promptly (4). Treatment usually requires hospitalization and may include antipsychotic medication, a mood stabilizer such as lithium, medication to support sleep, and in some cases electroconvulsive therapy (3,4). 

The challenge is where a person goes. In the United Kingdom, Australia, New Zealand, and much of Western Europe, mother and baby units admit the mother and infant together, so a woman can be treated by psychiatric staff while keeping her baby with her and getting help with care. The United States does not have a similar system. Postpartum Support International's national directory lists five inpatient perinatal psychiatric programs in the entire country: in Arkansas, California, Louisiana, New York, and North Carolina. Forty-five states have none. The unit at the University of North Carolina, the first of its kind when it opened in 2011, has five beds, and none of the five programs admits the baby overnight (15,16). Roughly two dozen states have a perinatal partial hospitalization or intensive outpatient program, but this is not an option for someone in acute psychosis (16).

So the default treatment in most of the country takes place in a general psychiatric ward, without perinatal expertise, lactation support, and without their baby. Mothers describe that separation as deeply traumatic and an obstacle to recovery, and some avoid seeking help specifically because they fear it (17).

The most severe symptoms may last several weeks, but recovery often takes six to twelve months or longer. Some people experience depression afterward or struggle to come to terms with what happened while they were unwell. Ongoing psychological and practical support can help during this period.

The risk of another episode after a future birth is significant (5,10), but that doesn't mean another pregnancy is off the table. Preconception counseling, specialist care, preventive medication where appropriate, sleep protection, and a clear postpartum plan can get people into treatment fast if symptoms appear (5).

The painful contradiction is that we know many of the risk factors. We know many of the early signs. We know that the illness can progress rapidly. And we know that treatment can work. Still, families often have to fight to be heard.

Suspected postpartum psychosis requires same-day help

If you think someone has postpartum psychosis, do not wait to see whether it passes. The person needs an urgent, same-day psychiatric assessment. 

Call whoever you can reach fastest, such as the OB-GYN or midwife, the baby's pediatrician, the psychiatrist or perinatal mental health provider if the person is already under one, or a local crisis line. Call or text 988 for the Suicide and Crisis Lifeline. If there is immediate danger to the mother or the baby, call 911 or go to the nearest emergency room. Say clearly that the person has recently given birth and that you are concerned about postpartum psychosis. Naming the condition changes how the call is triaged and how quickly they are seen.

Until help arrives, do not leave the person alone or solely responsible for the baby. Stay calm, and don't argue with them about delusions or unusual beliefs. Acknowledge that the person is frightened or overwhelmed, and focus on getting them somewhere safe.

Note important details and bring them to the assessment, such as dates, how many hours she has slept, particular things she has said, and what has changed. Because symptoms fluctuate, a single ER interview may not show a clinician what the family has seen at home. If the first provider brushes off the concern and symptoms continue or worsen, go back, or go somewhere else, and ask again.

Awareness cannot compensate for an inadequate system

Postpartum care in the US is fragmented by design. Obstetric care often ends without a clear handover to another service. The birthing parent typically gets one checkup around six weeks after giving birth, while the baby may be seen four or five times during the same period. This means the pediatrician may be the only clinician seeing a mother whose mental health is deteriorating, but pediatricians are not trained or paid to treat her. Emergency departments, primary care, and mental health services may each only see a fragmented part of the whole picture. 

Standard postpartum depression screening might not catch the warning signs either. Tools such as the Edinburgh Postnatal Depression Scale were designed mainly to identify depression. They do not directly ask about mania, confusion, reduced need for sleep, or rapidly changing behavior. Many clinicians also receive little training in recognizing postpartum psychosis, particularly when the person has no known history of serious mental illness (3).

The way the illness is classified does not help. Postpartum psychosis has no category of its own in the DSM, the main diagnostic manual used in the US. Its definition of postpartum onset is also narrower than the period clinicians recognize in practice (5,18). Without its own diagnostic criteria, the condition may be recognized and recorded differently depending on who sees the patient.

Access to care is another obstacle. Most states have extended Medicaid coverage to a full year after pregnancy, which is real progress. But having insurance does not mean there is a psychiatrist available. Large parts of the country still have neither.

Fear can also stop women from speaking openly. A mother may worry that she will be judged, separated from her baby, or labeled as an unfit parent (18). Even when a family asks for help, they may face long waits or be passed between services that are not equipped to respond.

Awareness campaigns cannot solve a shortage of specialist beds or a broken handover between services. Families cannot be expected to manage a psychiatric emergency simply because they have been told which warning signs to watch for.

Better care would begin before birth for women at higher risk. It would include clinicians who know the early signs, a clear route to emergency assessment, and access to treatment that keeps mother and baby together where possible. It also means taking families seriously when they say that someone they know has changed dramatically.

What we do afterward is also a choice

It is worth looking at how differently other countries handle these cases. Under the Infanticide Act 1938, the law in England and Wales already recognizes that a woman's mind may be disturbed by the effects of giving birth. It provides a route for cases involving the death of a child under 12 months to be treated as something other than murder (19). Around two dozen countries have comparable provisions (20,21).

The United States has no equivalent law (20,21). Illinois is the only state that refers to postpartum illness in its criminal code, and only as a mitigating factor at sentencing after a conviction (22). Everywhere else, the defense rests on state insanity laws written with other illnesses in mind. These laws vary considerably, and a handful of states have abolished the insanity defense altogether.

Postpartum psychosis can also be difficult to establish after the event. Experts may be asked months or years later to determine a woman’s state of mind at one precise moment. They must rely on medical records that may contain different diagnoses, or none at all, and accounts of symptoms that may have changed since then. And because roughly half of the women who develop postpartum psychosis have no documented psychiatric history, the illness is even harder to reconstruct retrospectively (18).

A clinical diagnosis does not determine legal responsibility. But when the law asks whether a woman understood what she was doing at the time, gaps in her records and the rapidly changing nature of the illness may make it harder to present an appropriate defense.

That is why the Clancy case came down to an all-or-nothing question about criminal responsibility, put before 12 lay jurors, concerning a state of mind that psychiatry itself cannot fully characterize (1,2). It is therefore not surprising that they could not answer it unanimously.

Compassion for someone accused of causing terrible harm is not the same as acquittal. It may reflect a sense that illness and responsibility do not fit neatly into the categories of "victim" or "monster." It may also reflect anger that the dangers of postpartum mental illness only command national attention when it is already far too late.

A courtroom may eventually settle the question of one woman's criminal responsibility. Whatever it decides, it will not answer the larger charge this case raises: why do we keep treating postpartum psychosis as an obscure footnote, and then act shocked when families do not recognize it?

We should not need a tragedy before a mother's loss of reality counts as a medical emergency. 

Where to get help

Emergency, or immediate risk to a mother or baby: call 911 or go to the nearest emergency room.

988 Suicide & Crisis Lifeline: call or text 988, 24/7.

National Maternal Mental Health Hotline: call or text 1-833-TLC-MAMA (1-833-852-6262). Free, confidential, 24/7, English and Spanish, open to partners and family members too.

Postpartum Support International: helpline at 1-800-944-4773 (call or text), with support groups, provider directories, and coordinators who can help you find perinatal psychiatric care in your state. postpartum.net

Your OB-GYN, midwife, the baby's pediatrician, or a perinatal psychiatry access line in your state can arrange an urgent assessment.