002: Lucid and psychotic — a deep dive into postpartum psychosis

In the wake of the tragedy in Duxbury, two reproductive psychiatrists clear up myths around postpartum psychosis, postpartum depression, and medication for mental health.

AND A LIE: This is the first installment of Two Truths’ “And a Lie,” a series that calls out and clears up fallacies, inaccuracies, misreporting, or other general BS that permeates pop culture, mainstream media, or your social feed. “And a Lie” delivers thoughtful perspective and hard facts so you can understand the truth about the issues you care about.

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Maybe it’s because Duxbury, Massachusetts is a town much like the small suburban town outside of Boston where I live, or maybe it’s because I, too, am a mother to young children. Maybe it’s because most Tuesday nights, I lead support groups for mothers; I’m welcomed into their worlds, I see their tears, and I hear their worries. Maybe it’s because I write about and advocate for maternal mental health for a living. Or maybe it’s just because I’m human. 

But when I saw the news about Lindsay Clancy—the mom of three and labor and delivery nurse recently charged with killing her three young children and attempting suicide—I was gutted.

Many of you were, and still are.

The story brought front and center—yet again—this country’s maternal mental health crisis. 

Today, some one in five to one in seven new moms experience a perinatal mood and anxiety disorder (PMAD), the classification of common, highly-treatable mood disorders such as postpartum depression and postpartum anxiety that occur in pregnancy or throughout the first year postpartum. In fact, postpartum anxiety and depression are so common that they are the number one complication of childbirth; per recent data from the Centers for Disease Control and Prevention, mental health conditions are the leading cause of pregnancy-related deaths.

But this case in particular sheds light on a rarer PMAD: postpartum psychosis—a condition that occurs in 0.1 to 0.2% of all births, is marked by delusions and hallucinations, and is considered a psychiatric emergency requiring immediate medical intervention and treatment.

As a journalist, I’ve watched the news cycle of this story unfold over the last few weeks, and I’ve noticed a few things. 

On one hand, there has been plenty of sound, educational, and even compassionate reporting on PMADs—a welcomed respite for conditions that are too often dismissed or stigmatized in society.

In the wake of the tragedy, The Boston Globe’s editorial board called for “every woman who gives birth in Massachusetts to be screened for maternal mental health disorders,” stating that “those who show symptoms need access to treatment that is affordable and culturally appropriate.” Such an announcement from a respected media outlet matters. It brings widespread attention to maternal mental health.

On the other hand, I’ve noticed plenty of inaccurate reporting: News stories have conflated the symptoms of postpartum depression with those of postpartum psychosis. I’ve seen maternal mental health conditions go wildly misrepresented or misunderstood in the media; or worse, pushed to the side in lieu of other narratives. I’ve heard moms ask: Could this have been me? 

There is plenty of important work being done to care for mothers’ mental health—no doubt. Since 2015, the American College of Obstetricians and Gynecologists (ACOG) has recommended that “all obstetrician-gynecologists and other obstetric care providers complete a full assessment of mood and emotional well-being (including screening for postpartum depression and anxiety with a validated instrument) during the comprehensive postpartum visit for each patient.”

It’s good, important work—and it’s not enough. Not all providers screen for maternal mental health conditions. Not all moms get screened. 

Even in 2023, it’s common for moms to not seek treatment. It’s common for moms to fear disclosing mental health symptoms for valid reasons—stigma, being deemed an “unfit” mother, and more. This is particularly true for Black and American Indian/Alaska Native moms, who not only face a higher maternal mortality rate than white mothers, but also have historically been discriminated against by both society at large and the medical field.

The ultimate result of all this: Mothers suffer. Families suffer. 

Over the past few weeks, my thoughts have returned to Lindsay Clancy, the deep demons that she must have been fighting that night for such a disaster to ensue, and to that home in Duxbury where those little lives were lost.

But ultimately, my thoughts have often returned to this question: What can we do as individuals when we know that this country must do so much more for mothers and families?

To answer that, I often return to something less tangible, less data-driven, yet nonetheless, an important prong in the treatment of PMADs: We can support mothers. A lack of support increases the risk for PMADs; having support in spades can smooth the postpartum journey. It’s easy to think that asking a new mom friend how they are really doing or holding space for someone’s darkest hours doesn’t matter; I will tell you that it does.

Recently, Two Truths caught up with two top reproductive psychiatrists—specially-trained doctors who study mental health throughout the reproductive years—for insight into two other key facets of PMAD treatments: medications for mental health and therapy. Below, our experts also clear up confusion around postpartum depression and postpartum psychosis, and provide resources on where to turn if you, or a friend, need help. Allow their words to inform you and assure you that the maternal mental health crisis is a preventable one.

Let them remind you that these issues should not fall on mothers to solve—and yet here we all are, part of the problem-solving. Two things can be true.

—By Cassie Shortsleeve 

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Meet our trusted experts—two leaders in the field of reproductive psychiatry.

• Lucy Hutner, M.D. is a Harvard- and Columbia-trained board-certified psychiatrist who co-edited the first textbook on women’s reproductive mental health. Dr. Hutner is a co-founder of the digital startup Phoebe and a strategic advisor for Gemma, a women’s mental health digital education platform centering impact and equity.

• Kara Brown, M.D. is a board-certified psychiatrist, a trainer for Postpartum Support International (a leading non-profit in the field of perinatal mental health), a member of the think tank Group for the Advancement of Psychiatry, and founder of NOLA Reproductive Psychiatry.

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Two Truths (TT): Let’s start with thoughts. We all have them, and we hear a lot about “scary,” “intrusive,” or “what if” thoughts postpartum. These thoughts are so common that one study found every single new mother experienced them. What are “intrusive thoughts,” and how are they different from “delusional” thoughts?

Dr. Brown: Intrusive thoughts are common in the perinatal period. Sometimes, they are symptoms of postpartum OCD and other anxiety disorders, but they can also exist on their own. Often, they surround the health and safety of the baby. How many new parents have expressed concerns over dropping their newborn baby? A lot! Intrusive thoughts are common and can be quite normal, especially when they occur infrequently and are not severely distressing. 

Sometimes intrusive thoughts can be more intense; I’ve seen mothers who’ve experienced intrusive thoughts of cutting their baby or throwing their baby out of the window. The mothers are simultaneously horrified by the thoughts and deeply shamed.

We call these types of thoughts ego-dystonic, meaning they don’t align with the core of the patient; these thoughts are repulsive to the woman who definitely does not want to act on them. These reflect thoughts that are very low risk of happening.

On the contrary, delusions are not grounded in reality. They are psychotic at the core and are ego-syntonic. Whereas the frightened mother with intrusive thoughts may take drastic measures to hide scissors around a baby she desperately doesn’t want to hurt, a mother suffering from delusions associated with postpartum psychosis may explain rationally why killing her baby makes sense to her within a psychotic framework. The two feel and are dramatically different.

TT: Thanks for that explanation. Now, can you help us understand postpartum psychosis?

Dr. Brown: One of the keys to understanding postpartum psychosis is understanding psychosis itself. 

TT: Let’s start there then. Help us understand psychosis.

Dr. Brown: Psychosis, at its core, is a separation or detachment from reality. When a person is psychotic, they are not grounded in reality. With postpartum psychosis, this often takes the form of delusions and hallucinations. Delusions are thoughts or beliefs that are not reality-based that others recognize as bizarre. A mother who believes her baby is inherently evil would be experiencing a delusion. Hallucinations are sensory experiences where one sees, hears, smells, or feels things that are not present. If I felt bugs crawling on me that were not present, I would be experiencing a hallucination. Someone may also experience “command hallucinations”—a voice telling them to do something, like harm their children.

These are psychotic symptoms that can occur with several illnesses; they’re not exclusive to postpartum psychosis. For example, less frequently, severe depression or mania in any individual can have a psychotic component to it; medical complications including prolonged insomnia also rarely can lead to hallucinations or delusions, as well. But we understand postpartum psychosis to be a different illness. 

TT: Okay, so what is postpartum psychosis?

Dr. Hutner: Postpartum psychosis is a rare condition. There is an association with both death by suicide (which occurs in approximately 5% of cases of postpartum psychosis) and infanticide (which occurs in approximately 4% of cases of postpartum psychosis). Even though the condition itself is uncommon and catastrophic outcomes are rare, the inherent risks mean that it should always be treated as a psychiatric emergency. 

A classic presentation starts quite rapidly within the first four weeks after birth. The person often feels very wired, like they can't sleep. They may be confused and seem to be in a delirium-like state. They become psychotic with paranoid ideas or hallucinations.

TT: Would the person experiencing it, or others around them, notice this to be strange?

Dr. Hutner: When postpartum psychosis happens, a person is typically way off their baseline; it is often clear to people around them that something is way off. 

Dr. Brown: Sometimes symptoms may be obvious to others, especially if the symptoms are being vocalized by the person experiencing them; but sometimes, all loved ones can articulate is that they know their wife/sister/daughter/mother has quickly become someone they don’t know, and they are scared. Having poor insight into one’s illness can be quite common with postpartum psychosis, so it may be difficult for someone to recognize postpartum psychosis happening to them. It can take a well-trained eye to determine the proper diagnosis, so having a trained provider weigh in is important.

TT: Could a mother with postpartum psychosis be both lucid and psychotic?

Dr. Hutner: One of the things that can be confusing about postpartum psychosis is that the symptoms can wax and wane—that is, the person can have both moments of lucidity and psychosis. Mothers with postpartum psychosis may be functioning in their lives and tending to their children, and still be having moments of psychosis. 

TT: Two things can be true. Now, we know that all PMADs have risk factors—a previous personal or family history of a mental health condition, a lack of social support, sleep deprivation, and more. For postpartum psychosis, the most significant risk factor is a personal or family history of bipolar diagnosis. Tell us more about that. 

Dr. Hunter: In general, we think of postpartum psychosis as a presentation of bipolar disorder. However, a substantial proportion of people with postpartum psychosis have no known psychiatric history—but just because someone doesn't have a diagnosis doesn't necessarily mean there wasn’t a mental health condition existing before. There are also some patients who experience postpartum psychosis and never have symptoms like it again; however, cases like this are rare.

TT: This makes sense. So tell us a bit about postpartum depression.

Dr. Hutner: Postpartum depression follows a classic presentation of major depression with negative ruminations, low energy, depressed mood, and difficulty sleeping. Postpartum depression and postpartum anxiety do not “turn into” postpartum psychosis. They are distinct entities. 

No matter the symptoms, it’s important to be evaluated by a mental health professional with training specifically in reproductive mental health. A skilled reproductive mental health professional can distinguish between them, even if some of the symptoms appear similar, such as difficulty with sleep.

TT: I’m glad you brought up the importance of finding a mental health provider who is trained in maternal mental health, since many are not. What are the potential consequences when providers aren’t specifically trained?

Dr. Brown: An unsafe provider who lacks the time or refuses to learn the difference between intrusive thoughts and delusions, and simply calls an ambulance in a situation where one might not be needed, risks traumatizing a family and perpetuating a culture of suffering in silence. It’s a challenge to find a balance between protecting people from potential harm but not over-stigmatizing illness or punishing those seeking help.

TT: So what are the solutions?

Dr. Brown: One important solution is education. We need more education for pregnant patients and family members. Providers also need to be educated so they can help accurately determine the risk of harm to one’s self or others. They also need the time to do so. 

TT: How do we find trained providers?

Dr. Brown: For one, Postpartum Support International contains a provider directory of trained professionals organized by state. If you are worried about your emotional well-being during pregnancy or postpartum, reaching out to a perinatal mental health provider sooner rather than later is very reasonable; I even see people in the preconception phase who feel better knowing they have a plan in place and a person to call prior to getting pregnant. It’s never too early to make a treatment plan when it comes to perinatal mental health, and it’s rarely too late to seek help when things go awry.

[TT note: Keep an eye out for the letters “PMH-C” after a provider’s name—they stand for “Perinatal Mental Health Certification” and indicate that a professional has at least two years of experience working with a perinatal population, received specific education and credentials, and has completed Postpartum Support International’s evidence-based perinatal mental health certificate training. Does everyone trained in reproductive or perinatal mental health have or need this certification? No. Are there other ways for providers to get trained in maternal mental health? Certainly. Could this be a starting point—a good indication that someone is specifically trained? Yes.]

TT: That’s such a good point. All PMADs are highly treatable. Treatment often involves a mix of social support, therapy, and medication. We’ve talked about the first two. Can you talk about the role of medication?

Dr. Brown: For most women with postpartum anxiety or depression who have never taken psychiatric medication before, SSRI antidepressants (such as Zoloft, Prozac, Lexapro) are the gold standard for medication—but there are always exceptions and nuance to discussing the best medication options. 

For those who are experiencing postpartum psychosis, mood-stabilizing medications (such as lithium or antipsychotics like Abilify, Zyprexa, or Seroquel) may be offered—but again, every person deserves a personalized discussion about the best option(s) for them. 

Dr. Hutner: These medications do their job very well when prescribed carefully and with the correct diagnosis. If someone has been correctly diagnosed as having postpartum depression and they are placed on an antidepressant, or if they have postpartum anxiety and are placed on a combination of an antidepressant and benzodiazepine and are monitored carefully, they can feel reassured that they are being treated for what they should be treated for, which is depression and anxiety. 

TT: Bottom line: There’s a lot of angst and worry right now among new moms. What do you want anyone reading this to know?

Dr. Hutner: A lot of my patients are terrified that if they have any sort of mood issue going on postpartum, they’re going to commit suicide or be at risk of harming their children. These cases are catastrophic, but they are fortunately rare. And no matter what the diagnosis, these are all treatable conditions. The difficulty is catching them—and that's why we want to erase the stigma and make it as easy as possible for people to access care.

TT: Absolutely. Thank you both for speaking with Two Truths.

If you are struggling with your mental health in pregnancy or new motherhood, know that you are not alone, it is not your fault, and with the right help you will feel better. 

Resources and further reading:

PMAD resources:

• Emergency assistance is available 24/7 at 911

• The National Suicide Prevention Lifeline is available 24/7 at 988

• The National Maternal Mental Health Hotline (1-833-9-HELP4MOMS) allows access to a trained counselor 24/7 and is available in Spanish and English

• Postpartum Support International provides educational resources on PMADs, free support groups, webinars, advanced trainings for providers, and more

• Postpartum Support International’s provider directory includes a list of thousands of trained professionals organized by state

• The Motherhood Center offers counseling, support groups, and webinars

• The Postpartum Stress Center offers educational resources, counseling, a referral list of trained providers, and advanced training for providers

We created this infographic for Chamber of Mothers to serve as a quick crash course in PMADs.

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