Lindsay Clancy trial highlights gaps in postpartum psychosis research, experts say

Kristina Delaney was five months postpartum when her husband saw something was very, very wrong. It was a Friday afternoon, and her husband had gone outside to make a phone call – concerned about his wife’s “hyperactive” speech.When he returned, she was rocking their two children in her arms, and said: “‘Please save us, please save our family,’” said Delaney. “And I thought Jesus was returning.”Now, Delaney believes she was in the throes of postpartum psychosis, a severe psychiatric illness that researchers estimate occurs in one to two per 1,000 women after delivery, the conservative equivalent of 3,600 US mothers each year.“It completely blind-sided our family – I’m a registered nurse,” said Delaney, now 41, and the founder of the non-profit advocacy group Cherished Mom. “I ended up spending two weeks in a psychiatric unit … and literally battling for my mind and my life,” she said.Experts and advocacy groups said the trial of Lindsay Clancy, a former nurse accused of strangling her three young children and then attempting to end her own life, has highlighted a misunderstood illness and a scientific debate about where, how and whether to include the little-known illness in “psychiatry’s Bible”, the Diagnostic and Statistical Manual of Mental Disorders (DSM-V).“It should not take a tragedy to start talking about postpartum psychosis and here we are – it’s outrageous it has become a viral topic after lives are lost and in a courtroom surrounding Lindsay Clancy,” said Delaney.Clancy’s defense attorneys have argued she was suffering from postpartum psychosis at the time she is accused of killing her children. Her symptoms included anxiety, insomnia and depression. She also received inpatient treatment at McLean hospital, was prescribed psychiatric medications and searched for terms such as “psychosis” on her computer. Prosecutors argued Clancy was a deliberate killer who sent her husband out for errands so she could kill their children.On 4 September, Judge William Sullivan declared a mistrial after the jury remained deadlocked despite deliberating for more than a week.‘We still know so little about the illness’Symptoms of postpartum psychosis include mania, depression, psychotic features and “mixed episodes”. Researchers have hypothesized the illness is related to bipolar disorder, and that it could have a genetic basis triggered by the immune system changes and hormones fluctuations brought on my pregnancy. Onset can be sudden or gradual, and is typically severe.“Women have lost touch with reality at the point when they’re caring for a vulnerable baby, so the risks to the baby are high,” said Jessica Heron, a psychologist and chief executive at Action on Postpartum Psychosis, a Swansea Wales-based advocacy group. “It has to be taken seriously – that’s why mother and baby care is so important.”Nevertheless, infanticide is incredibly rare, including among women with postpartum psychosis. There are roughly 1,200 cases of postpartum psychosis per year in the UK, with “a few cases per decade” of infanticide, according to Heron. In the US, current epidemiological estimates of one to two cases of postpartum psychosis per 1,000 deliveries. Comparatively, rates of infant homicide are rare, at 7.11 per 100,000, according to the Centers for Disease Control and Prevention (CDC). Women are at higher risk of hurting themselves, experts said.“We’re really in the middle ages here,” said Dr Veerle Bergink, director of the Women’s Mental Health Center at Mount Sinai hospital in New York. “The Lindsay Clancy [trial] shows how ugly it gets with social media and people saying all kinds of things about postpartum psychosis, because they are not educated on it, because medical doctors do not learn about it, gynecologists or psychologists – because it does not exist in classification systems.”However, adding a new diagnosis to the DSM is no small feat. Many proposals are submitted each year by the research community, all of which require evaluation by committees of expert editors. The last update to the DSM involved more than 200 experts working across four key topics. Among them is Dr Kimberly Yonkers, chief of the Yale New Haven Health Division of Psychological Medicine, and lead of the gender study group for revisions to the DSM.“I think everybody agrees there’s something here,” said Yonkers. “There needs to be some attention to how this fits in the manual, what the criteria should be, where it should be,” she said. “It’s a pretty rigorous scientific approach to the addition of a new diagnostic category. People are not always happy with that.”Berginke and advocates for inclusion have been frustrated in part by what they see as a circular problem caused by its absence from the DSM. Without a formal entry, it is difficult to fund research on postpartum psychosis, difficult to educate providers and families, and ultimately difficult to close gaps in care.Postpartum psychosis is one of psychiatry’s “strongest phenotypes”, Berginke argued, a rapid onset disorder that often impacts women with no history of mental illness.“It’s an illness that’s been reported since ancient Greek times,” said Heron. “There are so many historical reports of this very sudden dramatic illness happening after childbirth that it feels shocking that we still know so little about it.”Yet, postpartum psychosis is also very treatable. Response to treatment with lithium and electroconvulsive therapy “is excellent”, according to a research review in Biological Psychiatry, in which Berginke was a co-author.This is not the first case of postpartum psychosis on trial in the US. Andrea Yates was accused of drowning her five children in a bathtub in 2001, and was convicted of murder a year later. Her conviction was overturned due to false testimony from a prosecution witness, and in 2006 she was found not guilty by reason of insanity. The case led to a legal fund now overseen by Postpartum Support International, a group that also supports inclusion in the DSM.“There’s a lot of things the trial is pointing out – the inconsistencies, the lack of diagnostic criteria, certainly the lack of awareness, the gaps in the healthcare system – that I hope that we are not only pointing out through this trial but somehow we can move forward and expect change, and that this conversation does not stop, because it can’t,” said Delaney.