Peripartum Depression and Psychosis - The Ignored Basics

 

This is just a sampling of headlines about a current case of postpartum depression and psychosis and an ongoing trial for homicide.  A woman killed her three children and her defense is decreased criminal responsibility due to a mental disorder.  I do not know any of the actual details of the case, but I do know this clinical situation very well for a number of reasons.

I was an acute care psychiatrist of 22 years and in that capacity treated many cases of this disorder, including cases associated with homicide where I was called to testify in both criminal court and civil court.  In doing evaluations of women with recurrent psychotic disorders, it was apparent to me that many had the onset of that disorder during or immediately after a pregnancy and it was never adequately treated. Practically all of those women had bipolar disorder, but given the inadequate treatment and chronicity – the diagnosis was typically modified to schizoaffective disorder.

During my career, I quickly learned that a detailed history of all of the pregnancies in a woman’s life was extremely important.  In many cases it was associated with a new onset of a psychiatric disorder.  Those disorders were often not treated even when it was clear they resulted in permanent changes. My clinical experience is reflected in the literature where 50-75% of women with depression and anxiety are undiagnosed (1).  In those populations there is a significant prevalence of suicidal ideation and variability in available screening.  Only a fraction of woman diagnosed with depression get adequate care at about the same rate of adequate care as the general population (10% vs 17%) (2).     

In the 1980s and 1990s psychiatric care for women during pregnancy was often lacking due to concerns about medication toxicity to the fetus. During that era, psychiatrists specializing in women’s health became more visible and started to address major issues like the timing and type of treatment recommended for perinatal and postpartum psychiatric disorders.  That included decisions about not stopping medications during pregnancy, breastfeeding, and reviewing the results of these strategies. 

As it became known that I was interested in the problem, I started to get self referrals. They were usually women who were told they could not take their psychiatric medication during pregnancy or in the immediate post-partum state.  These women were concerned about their mental state without maintenance medication especially the ability to function as well as suicidal ideation.  Several psychiatric colleagues practiced in a woman’s health clinic at that time and were treating the same population.

Without going too far into detail, all of these conditions that women experience in the postpartum state are very serious conditions.  They tend to be minimized by saying it is something that most women go through and must endure.  A universal experience almost always invites group comparisons that rarely apply at the individual level.  There should be no conclusions that one experience is the experience that everyone has. 

The women I treated had very serious disorders at all stages of pregnancy whether there were outpatients on hospitalized on an inpatient unit.  In some cases, I had to reconstruct what happened during a pregnancy they experienced 10 or 20 years earlier and how that applied to their current experience.  Some were disabled, not able to work, and had disruptions with significant relationships in their lives. 

I have posted about this in the past and a remarkable approach to treating perinatal disorders in the Netherlands.  At the time I wrote this post nearly a decade ago, there were specialty units called maternal-baby units (MBUs).  In the study woman with psychosis or mania within 6 weeks of childbirth were admitted and stabilized. Most were treated with lithium or antipsychotic monotherapy and followed for 9 months.  The discharge goal was remission of symptoms for one week prior to discharge and the average length of stay was 55 days.  Functional outcomes were very good.  In the original post, I made the observation that none of this care would have been possible in the US.  At the time there were no MBUs.  All inpatient psychiatric units where I have worked were suboptimal settings basically due to business management tactics. 

An ideal inpatient setting for mothers who are either pregnant with a perinatal disorder or a postpartum state would be a supportive environment that is environmentally pleasing, calm, clean, and has access to obstetric services.  I will be the first to say that as an acute care psychiatrist – I have never seen such a place.  I have talked with many patients who refused inpatient care based on what the environment was like.

The environment is probably the most critical factor in treating a person with a severe psychiatric disorder.  They should feel safe and cared for.  They should encounter staff dedicated to optimizing the inpatient experience.  The concept of asylum comes to mind as an environment that is a stress free and safe.  Lamb (3) defines it as “sanctuary, a place that lowers levels of stress and provides protection, safety, security, and social support, as well as an array of treatment services.”  I would add that there needs to be frequent contact with the treating professionals – especially in the cases where there is unpredictability, symptoms of psychosis, and impaired judgment. That frequent contact should involve ongoing assessment as well as psychotherapy. 

The reason for optimizing the environment is to encourage the necessary level of communication for diagnosis and treatment.  It should be obvious but anyone who feels trapped on an inpatient unit – is not going to communicate freely.  They will say what they think they need to get discharged.  That may include covering up significant symptoms.  I have had people tell me this - weeks after discharge. At some point the patient must be engaged in a process that not only addresses their acute symptoms but also longer-term risks.  In the case of severe peripartum disorders that includes both suicidal and aggressive ideation. The therapeutic process is interwoven with the assessment of safety in the home environment.

I am very confident that psychiatrists can diagnose and treat these problems.  I am also very confident that there are serious legal, cultural, and political obstacles to care.  There is the problem of a low standard of care on inpatient units that is the product of business and political rationing of care.  There is a prominent problem with cultural processing of peripartum psychosis with filicide.  There is currently only one state (Illinois) – that explicitly recognizes the effect of the postpartum mental illness on culpability (4).  It does not replace the not guilty be reason of insanity (NGRI) defense but allows for mitigation during sentencing to reduce lengthy incarcerations.

The need to use a general NGRI defense for infanticide or filicide associated with peripartum states is highly problematic.  Only about 1-6% of general felony cases use the NGRI defense and in those cases, it is successful about 12-17% of the time.  The defense became more restrictive after the Hinckley verdict in 1982 when 36 states modified their statutes and that included 4 states eliminating the defense.  Successful defense generally depends on the diagnosis of a psychotic disorder or a mood disorder with psychotic features. States of intoxication and personality disorders are generally not successful with this defense, but there is likely some overlap between both sets of conditions.     

An NGRI diminished capacity defense rests on the reality that the behavior is driven by symptoms of psychosis and not malice. Enduring these experiences results in intense grief, guilt, and regret (5).  Future harm to the mother is significant with up to 30% dying by suicide and high risk of both future severe mental illness and poor maternal infant attachment.  Partners experience the loss of relationship and planned future of the relationship in addition to a lack of knowledge about the condition (6). 

One of the useful conceptualizations of these disorders and their impact comes from family systems theory.  A perinatal mental disorder compromises the entire family’s ability to function (7).  Reviews invariably consider the problem of peripartum mental illness associated with infanticide/filicide as one of missed opportunities for screening, intervention, and access to care. 

What is not useful is a binary framing of the perpetrator and victim.  At the level of media and culture there is the killer mother trope that splits people who want to help from people who want to blame. That adversarial framing impacts the entire family going forward and obscures potential points of intervention and prevention.  Like most polarizing situations – the amplification is evident today with monetization and political gain from the divisiveness a primary consideration.  I consider the elimination of Medicaid - the single largest source of maternal care in the US to be both an end result of this split as well as a potential cause of more of these cases.

In the final analysis it is easy to blame one person for the catastrophic outcomes associated with perinatal mental illness and infanticide/filicide. You can pretend that modern society is not a cooperative effort with division of labor and resources. You can pretend that you don't have to care about anyone else other than you and your immediate family.  You can pretend that people who really need help are freeloaders, criminals, malingerers, or just too weak to survive on their own. But that is an poor analysis of the problem.  Families, parents, and children need to be supported in ways that foster growth and security way before there are catastrophic outcomes.

  

George Dawson, MD, DFAPA

 

1: Solomonov N, Kerchner D, Dai Y, et al. Prevalence and Trajectories of Perinatal Anxiety and Depression in a Large Urban Medical Center. JAMA Netw Open. 2025;8(9):e2533111. doi:10.1001/jamanetworkopen.2025.33111

2:  Vigo D, Haro JM, Hwang I, et al. Toward measuring effective treatment coverage: critical bottlenecks in quality- and user-adjusted coverage for major depressive disorder. Psychol Med. 2022 Jul;52(10):1948-1958. doi: 10.1017/S0033291720003797. Epub 2020 Oct 20. PMID: 33077023; PMCID: PMC9341444.

3:  Lamb HR, Weinberger LE. Rediscovering the Concept of Asylum for Persons with Serious Mental Illness. J Am Acad Psychiatry Law. 2016 Mar;44(1):106-10. PMID: 26944750.

4:  Tabb KM, Hsieh WJ, Ramirez XR, Kopels S. State legislation and policies to improve perinatal mental health: a policy review and analysis of the state of Illinois. Front Psychiatry. 2024 Apr 18;15:1347382. doi: 10.3389/fpsyt.2024.1347382. PMID: 38699448; PMCID: PMC11064060.

5:  Milia G, Noonan M. Experiences and perspectives of women who have committed neonaticide, infanticide and filicide: A systematic review and qualitative evidence synthesis. J Psychiatr Ment Health Nurs. 2022 Dec;29(6):813-828. doi: 10.1111/jpm.12828. Epub 2022 Mar 24. PMID: 35255182; PMCID: PMC9790608.

6:  Lyons T, Hennesey T, Noonan M. A systematic review of qualitative evidence: Perspectives of fathers whose partner experienced postpartum psychosis. J Adv Nurs. 2024 Feb;80(2):413-429. doi: 10.1111/jan.15832. Epub 2023 Sep 1. PMID: 37658618.

7:  Wisner KL, Murphy C, Thomas MM. Prioritizing Maternal Mental Health in Addressing Morbidity and Mortality. JAMA Psychiatry. 2024;81(5):521–526. doi:10.1001/jamapsychiatry.2023.5648

8:  Alford AY, Riggins AD, Chopak-Foss J, Cowan LT, Nwaonumah EC, Oloyede TF, Sejoro ST, Kutten WS. A systematic review of postpartum psychosis resulting in infanticide: missed opportunities in screening, diagnosis, and treatment. Arch Womens Ment Health. 2025 Apr;28(2):297-308. doi: 10.1007/s00737-024-01508-3. Epub 2024 Sep 2. PMID: 39222077.