What does the Lindsay Clancy trial tell us about treating maternal mental health?

0:00It's Consider This where every day we go deep on one big news story. Today, what the Lindsay Clancy murder trial reveals about maternal mental health care. Clancy, a Massachusetts woman, does not deny killing her three children. Prosecutors say the murders were intentional. They were strangled, deliberately and meticulously killed by this defendant on January 24th of 2023. But her defense team argues she was suffering from severe postpartum psychosis. This is the scariest mental illness that I know of. Dr. Susan Hatters Friedman is a reproductive and forensic psychiatrist. She told WBUR's Deborah Becker that postpartum psychosis is not listed as a distinct diagnosis in what's known as the DSM.

0:52That's the handbook used to identify mental health conditions. so patients often have a hard time getting proper care. You look at the records of her Googling drugs. You look at how many times, how many hours of the night, in the afternoon, she's looking this stuff up. That is Clancy's defense attorney, Kevin Reddington, during closing arguments last week. In between taking care of the family, in between all the stuff that was going on, visiting doctors, seeing doctors, going to Rhode Island, being told, no, we can't help you. Calling a suicide hotline, we can't help you. Calling another suicide hotline, we can't help you.

1:31My God, what does she have to do? She was reaching out for help, and she was not getting it. The case has put a spotlight on maternal mental health, with people showing up to support Clancy outside of the court. We're here to send one message, and that message is that it should not take tragedy for people to start paying attention to mental health. Consider this. The murder trial of Lindsay Clancy has brought maternal mental health to the forefront. What have we learned about how to address it?

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3:16It's Consider This from NPR. Lindsay Clancy's case has resonated with many women who feel that maternal mental health, particularly after giving birth, is not taken seriously enough. What might be learned from the public response to the case? Dr. Julia Riddle is a reproductive psychiatrist and professor at the University of North Carolina Chapel Hill Center for Women's Mood Disorders. So, Lindsay Clancy does not deny killing her children. She says she was suffering postpartum psychosis. And so I want to begin there just by defining that term. What is postpartum psychosis? What are the symptoms?

3:58Deborah Becker:Yeah, postpartum psychosis, it's often a misnomer, which makes it hard out of the gate. But we talk about it as an affective illness, which means a mood disorder. It looks a lot like what we call a delirious mania. The delirious part meaning waxing and waning. So a woman can look like herself and act like herself for a few hours. And then the next minute, hour, can be completely taken over by these psychotic and manic symptoms being delusions. So delusions being what we call fixed false beliefs. The world is not safe. Something terrible is going to happen. Something terrible is happening. As well as hallucinations.

4:37Deborah Becker:So those are the things, hearing things that other people can't hear, seeing things that people can't see. But as well as that manic side of things. So often there's this activation, lack of sleep, kind of doing things that are very odd, often driven by delusions that women can't actually articulate to us and often can't remember once they get through an episode and get back from it. So it happens epidemiologically. Current estimates are around one to two in a thousand births. The genetics tell us that it's pretty closely related to bipolar disorder, though not in all cases. So there's a big signal in the relationship to bipolar disorder.

5:15Deborah Becker:Sometimes this is the first episode that someone has of a bipolar affective disorder, And sometimes it's just an isolated episode in the postpartum. We consider it a psychiatric emergency. A psychiatric emergency. That's helpful to just hear you walk us through it because what you're describing sounds like an entirely different condition, an order of magnitude, from the feelings of exhaustion or being overwhelmed that so many new parents feel. Yeah, that's exactly right. And we talk a lot, and I think in what we do, and I think this resonates with women all the time, there's so much normalizing.

5:56Deborah Becker:Of course you're not sleeping. Of course you're overwhelmed. Of course you're, you know, kind of crying or maybe you get overwhelmed at times. Or scared that everything's going wrong because everything feels out of control. Scared that everything is going wrong, worried about your child's health. And so it can be really, really hard. And we see it often that early on when people are not, you know, when a partner or a family member is seeing this woman, they're working really hard to make it make sense because they know this person. Oh, maybe they just need a bit of sleep. And then they try to tell them to go take a nap, but they actually find them pacing.

6:29And so, you know, we know the data shows us that 50 % of the time it is missed because

6:36Deborah Becker:I didn't even talk about it being in training or in the DSM. But you're right. It's very different than just feeling a little down. It's very different than the baby blues. It's very different than just worrying if your baby's gotten enough milk and they're, you know, resting well. It's not that. It's a lot more of these really serious symptoms. You're also describing something that sounds very difficult to diagnose because, as you said, the symptoms can appear for a few hours. And then the woman may feel like herself, may present as herself. That must be incredibly challenging for doctors trying to figure out what is going on.

7:14Deborah Becker:Yeah. I mean, what we do feels so high risk so often. And a woman, what we often talk about is, you know, women, people, not just women, but people can pull up from quite a reserve in certain situations. So you can imagine if a woman comes to an ER and she's been displaying very odd symptoms at home, in that time when she's getting evaluated, she may say, she may be able to pull up enough reserved to hold herself together to say, oh, I'm just a little worried and not sleeping well. We often talk in medicine about horses and zebras, horses being common things. It's very common to have postpartum depression.

7:48Deborah Becker:It's very common to have postpartum anxiety. Sleep and worries can be part of that. It's not as common to have postpartum psychosis. And so it does become sort of in these cross-sectional examinations, hard to know without, we don't have those biomarkers, we don't have those tests to be able to say in this moment, okay, is this just a little bit of anxiety and sleep or is this something bigger? And we usually get at that by observation, by the pattern recognition of what we do, and actually by talking to their community, because we will have someone in their family or their therapist or someone that knows them that says this is not them.

8:24Deborah Becker:I know they're telling you that, but let me tell you how they're actually acting at home. And so it does make it so hard and so high risk in terms of taking care of these patients and knowing what we're seeing. Yeah. In your practice, what are you hearing from your patients? What are you hearing from colleagues who I imagine are watching this trial closely? Yeah. It's a great question. And when this case first happened in 2023, I heard about it first actually from my patients. I mean, I knew about it because of what I do, but my patients, and really it separates it a little bit. It's really my patients with OCD and with anxiety that are so scared.

9:07Deborah Becker:This is the scariest thing I think that any of us could ever imagine happening in our lives. And it's what makes it so hard to think about, to sit with, honestly, to watch, to have so pervasive in the media that patients are so scared that's going to be them. And so I always do want to really articulate these are treatable illnesses, one. but two having anxiety having depression having ocd does not mean you're going to have postpartum psychosis and so you hear it from patients because this is the scariest outcome they can ever imagine of being someone that's ever had intrusive thoughts or ever had frustrated thoughts with their child they think oh my gosh what if it flips what if i start to what if i did what if i acted on that because they have no intention of doing that and then from colleagues i i feel you know i'm very fortunate i work in a training institution i work with a lot of trainees and many of my trainees are reaching out to me just to talk about it, to make sure that they're doing their gut check, to think about, am I thinking through this right?

10:05Deborah Becker:I also work on NC Matters, which is an access line in the state of North Carolina. Many states have their own versions of access lines, which is that obstetricians, psychiatrists, family medicine doctors, therapists, genetic counselors, it's an access line where you can reach a perinatal psychiatrist to talk with them about a case or a patient. And we are hearing - So someone with specific training in postpartum psychosis, as opposed to somebody who may be staffing a general suicide crisis hotline. Exactly. Right. Exactly. So you can get through it through the PSI international line, the maternal mental health line, but it really provides you with direct act, exactly, to get that specialized care and resources.

10:48Deborah Becker:And so what we are hearing from a lot of, in North Carolina, our affiliates, and that I'm hearing is also, hey, could you do a training with us just to kind of, so that we can think through intrusive thoughts and, you know, these delusional thoughts. So people are thinking about this. I think I've spoken about this before, but, you know, reproductive psychiatry and perinatal psychiatry is not a required part of any medical training, let alone therapy training. And so I think our trainees are very lucky that they've gotten this specialized training just because it's a something we do here at UNC.

11:23Deborah Becker:But everyone is just thinking, oh my gosh, this is so high risk. How can I make sure that I'm thinking about this right and doing justice to the women that I'm serving and families? Have you been surprised by the people coming out to support Lindsay Clancy outside the court since the trial got underway? So, you know, when you ask someone who's in this work so deeply like I am and others in this work, it's really hard to be talking about this via a criminal case because I want to acknowledge how much I am not knowledgeable about the criminal side of things and that's so specific and in some ways heartbreaking that this is the reason that we're talking about it.

12:05Deborah Becker:But can I understand why when you see this happening that it may swell up in a group of people, kind of fears about the postpartum, feeling like, oh my gosh, I'm a mother too and the postpartum was hard. and gosh, I tried so hard to get my own help and it was difficult that I can absolutely see how there can just be a groundswell of women experiencing a sense of just how hard the postpartum can be and how heavy that all is. I don't know that I would have predicted it, but none of the points that are being raised are a surprise to me because of what I do, if that makes sense. It does. I wonder, for all of the horror of this tragedy, it sounds as though what I'm hearing from you is at least the possibility that the spotlight could help change the national conversation, the healthcare conversation could maybe open up greater availability of resources to support women.

13:17because obviously nobody wants to see anything like this ever happen again.

13:22Deborah Becker:You know, that is the hope. And I would go even further to just say that it, the hope, the dream, if I can dream, and then I'll have my practical take on it. But the dream is that it inspires us to, you know, we always say it takes a village to raise a child, but it takes a village to take care of a mother and a family. And we have put that whole village often just on a woman and maybe on her partner. And how can we continue to expand that village? That's via paternity leave for all parents involved. That's via more community resources, via just more knowledge in this country of how to be family friendly in ways that allow for a lot more kind of porous ways of being with each other and looking out for each other.

14:10Deborah Becker:So that when things do happen or people do change or people are suffering, there's more people around to say, hey, we got to get you to health. and then absolutely I hope that I hope that as this brings attention to a how difficult it is in psychiatry to do the real research that we're not invested in enough and that we really we can do a lot better and I think that that is absolutely the pipe dream is the fear that when this ends it's it's do we want it to end so badly because it's a lot to encounter this I think as a society but is the fear that it becomes a flash in the pan and we go back I think that is a real a real fear.

14:44Deborah Becker:And I hope that this does inspire us to think about how are we investing? How are we thinking about risk assessment so that we can figure out who is at risk before the illness arrives so that we can get them into care so that we can expand where we're doing that. And we're thinking about that both in literal ways, how people are doing it, but also where we're investing our money and kind of that we're walking the walk as well. It's reproductive psychiatrist, Dr. Julia Riddle. Dr. Riddle, thank you. Thank you, Mary Louise. This episode was produced by Megan Lim and Karen Zamora, with audio engineering by Eowyn Fane and Ted Meebane.

15:23Our director is Jonas Adams. It was edited by Justine Kinnon and Tenbeat Ermus. WBUR's Deborah Becker contributed reporting in this episode. Our interim executive producer is Courtney Dorning.

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