A Mother Charged with Killing Her Children: A Possible Explanation for the Unthinkable
Flowers left at 47 Summer Street in Duxbury, Mass., in memory of two children allegedly killed by their mother. Postpartum psychosis could offer an explanation for the unthinkable. Photo by David L. Ryan/the Boston Globe via Getty Images
A Mother Charged with Killing Her Children: A Possible Explanation for the Unthinkable
Q&A with a BMC nurse-midwife on the importance of recognizing and treating postpartum depression and psychosis
Editor’s note: On Friday, January 27, the third child in this incident, a 7-month old infant, also died, according to prosecutors.
To many people, it’s unthinkable. This week a Duxbury, Mass., mother allegedly killed two of her three children and seriously injured the third, a seven-month-old infant, then tried to kill herself by jumping out of a second-floor window.
People reacted to the tragedy with shock and grief, but many guessed a possible cause: postpartum psychosis, a rare and severe form of postpartum depression triggered by the massive hormonal changes experienced by new mothers.
No one knows if that’s what drove Lindsay Clancy, 32, who is in police custody in a Boston hospital, charged with strangling her five-year-old daughter and three-year-old son to death and injuring her seven-month-old son. But Clancy’s social media posts reportedly referenced postpartum issues after the birth of one of the older children.
“This is not the baby blues, this is a severe disease,” says Rosha Forman, an assistant professor of obstetrics and gynecology at the Aram V. Chobanian & Edward Avedisian School of Medicine and director of midwifery services at Boston Medical Center. “It’s very sad and very scary, and all we can do is try to keep close eyes on people and educate, educate, educate.”
In one more awful twist in the story, reportedly Clancy is a labor and delivery nurse at Massachusetts General Hospital and would have been familiar with the warning signs.
“What that would tell you is that nobody is immune, no matter how much education you have, no matter how much knowledge you have, these are things that are chemical,” Forman says. “But again, I don’t know what happened in this case.”
A midwife at BMC for 13 years, in her current role Forman sees 40 to 50 women a year through their pregnancy and beyond delivery. She says perhaps 20 percent have mild to moderate postpartum depression; she has seen only two patients with postpartum psychosis in her career.
We asked Forman about the causes, warning signs, and treatment of the condition. “I’m happy to use any opportunity to spread the word about postpartum depression and postpartum psychosis,” she says.
Q&A
with Rosha Forman
BU Today: How does postpartum depression figure in your work?
Forman: Most of our care focuses on the care of the pregnant person through six weeks postpartum and beyond. And so a big part of our job is postpartum care and that transition to primary care. We do screenings for depression three times during the pregnancy and then at the two- and six-week postpartum visits, and mental health ends up being a lot of what we do. We do the screening and diagnosis, but not the therapy. And if we can build trusting relationships with our patients, which is our goal, and I think, our outcome, they’re more likely to disclose what they’re really truly feeling, and we’re more likely to be able to get them connected with the services that they need—psychiatric or behavioral health and mental health services.
BU Today: What causes postpartum depression?
Forman: The cause is multifactorial. I mean, like any disease, like cancer, you don’t know the exact cause. One thing that’s happening in the body is enormous: hormonal fluctuations that happen once the baby and the placenta leave the body. So estrogen and progesterone and testosterone levels—a lot of the hormones that control a lot of the reproductive life cycle—are flipping and flopping all over the place. That’s a higher risk factor for emotional and mental health. There are other risk factors that contribute: environmental exposures, lifestyle, those kinds of things.
It being your first baby is a risk factor for postpartum depression. Traumatic birth can be a risk factor for postpartum depression. Severe anemia can be a risk factor. So basically, if your physical body is not well and you’re coping with all of those changes, it’s more likely that your emotional state is not well. But there are plenty of people that have a traumatic birth or have an unhealthy body and don’t get depressed. It’s not causal, but it does increase your risk.
BU Today: How often do you see the far end of the spectrum, postpartum psychosis?
Forman: Not even once a year. Honestly, I have seen it in my career twice—neither one of which manifested in aggression towards their babies. But they manifested in hallucinations and hallucinatory thoughts, and they were both very striking in presentation. But I see postpartum depression a lot, you know. I think the statistics say, between 6 and 20 percent of people have postpartum depression. And I would say, I see closer to 20 percent.
BU Today: There’s a wide range of severity here?
Forman: It goes from “baby blues,” which almost everyone experiences, which is just feeling tearful, kind of crying at the commercials. You hear your favorite song, and the tears flow. That’s not so worrisome. That’s really more of a part of what should be expected with that hormonal transition. And then in the middle, you have kind of a more severe postpartum depression that doesn’t clear up after two to six weeks. And then postpartum psychosis is the end of that spectrum of postpartum mood disorders.
BU Today: The more serious forms respond to treatment?
Forman: It generally requires medication and hospitalization while they stabilize, but absolutely it can be treated. Being diagnosed is really important, because with all mental health disorders, the longer something goes on, the harder it is to right the ship. So I think that early recognition and diagnosis is really essential.
People will say, “I started to feel like something was off, but I knew she was super tired,” and maybe don’t recognize the signs that things are turning into a really bad space early enough. This is not to place any blame on their support. But that’s one of the reasons I wanted to talk about this. I say to people, if you feel like she’s just not her normal self or she really doesn’t have that regular sparkle in her eye, or she’s saying anything that makes you feel worried, don’t wait. Just give us a call.
BU Today: What else do you look for?
Forman: The largest risk factor for postpartum depression is a history of depression. If a person has had a history of depression prior to their pregnancy or during their pregnancy, it is really important to talk to your provider about that, to disclose that information, and for some people I’ve started them on SSRIs [selective serotonin reuptake inhibitors, a class of antidepressants] about a month before birth, in preparation for that postpartum depression episode to occur.
If you had postpartum depression with your first baby, you’re more likely to have it with your second and third, absolutely. And people who we’ve seen that have had a really tough time, we make sure they’re seeing behavioral health providers during their pregnancy, even if they’re like, “I’m fine now.” I’m like, “No, no, no, so you need someone you trust that you have on your speed dial, that you can call when you are not feeling well this next time.” And some people don’t get depressed again. It’s certainly not like a curse that you will always be depressed, but they are the people we keep our eyes on, more to make sure that we can preempt a severe depressive episode.
BU Today: How do you diagnose this?
Forman: We use a postnatal screening tool called the Edinburgh Postnatal Depression Scale. It’s a little bit better than the tool called the PHQ-9 [patient health questionnaire], because the PHQ-9 asks questions like, Are you tired all the time? And everyone’s like, yesss. And, are you sleeping well? Nooo. This one is a little bit more targeted. And there’s a range, depending on your score. You get like a mild, medium, or severe, and so we would target our intervention to sort of how worried we are about the person. If anybody discloses any suicidal or homicidal thoughts or intentions, we have emergency behavioral health services that we’ll call in and do a warm handoff. If we think someone is just a little down, but very clearly not suicidal or homicidal, we might be able to put in a referral for a visit within a week or something.
The mental health services in this country right now are kind of in crisis, and there is way more demand than there is access, and I think something like postpartum care often will get bumped up in terms of priority, because it’s such a time-specific event. But I don’t want to paint too glossy a picture on this topic. There’s too much demand for quite a small system. I think we need more. We need more mental healthcare providers. We probably need better pay for mental healthcare providers. We need more people who specialize in caring for perinatal mental health disorders, so people can really get these services in a timely fashion.
BU Today: Are there warning signs that mothers should be aware of?
Forman: The phrasing we use is, if you have any thoughts of hurting yourself or hurting anyone else or you have disinterest in caring for your baby. I think that’s one of the real warning signs that I see for severe postpartum depression or postpartum psychosis. If a mom is so depressed that she is not interested in caring for her baby anymore, that to me is a warning sign. Way before thoughts of harming the baby. We want to make sure to promote maternal-infant bonding. And if that is not happening, that is a real, real danger.
BU Today: What else should we know about?
Forman: One thing I didn’t mention that’s another piece of the spectrum is severe postpartum anxiety, which generally doesn’t lead into psychosis and hurting people, but can be very detrimental to health, and I think it’s probably underdiagnosed. The anxiety would be particularly about caring for your baby, keeping your baby safe, your baby breathing. It can get a little bit irrational. People can be not able to sleep because they need to watch their baby breathe. All the time. They don’t want anyone to touch their baby. We use the same interventions as depression. Anxiety is not a fun feeling, and it can get very intense in that postpartum period, when you are tasked with caring for the person you love more than anyone in the whole world. And they’re very vulnerable. And you have huge hormonal transitions, and you’ve never done this before. It’s a big deal.
If you or someone you know has thoughts of harming themselves, Call 988 or go to 988lifeline.org to chat with someone at the Suicide and Crisis Lifeline. Call 1-833-943-5746 (1-833-9-HELP4MOMS) to contact the National Maternal Mental Health Hotline.
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