Shumita Basu, Narrating: Hi there. A warning before we get started: This episode includes descriptions of violence and mentions suicide. If you or someone you know is struggling or in crisis, please contact the Suicide & Crisis Lifeline by calling or texting 988.
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Basu, Narrating: This is "In Conversation" from Apple News. I'm Shumita Basu. Today, how we don't take postpartum mental health seriously enough and what that means for new parents.
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Basu, Narrating: Lindsay Clancy had a life that many people wish they had. She lived with her family in a suburb outside of Boston, had a good job as a labor and delivery nurse at Massachusetts General Hospital, a husband and three children, who she often posted about on social media: a picture of the kids with their backpacks on the first day of school, in matching plaid outfits on Christmas, out for a run with one child in a stroller.
Jessica Winter: She really had this picture-perfect existence.
Basu, Narrating: That's "New Yorker" editor Jessica Winter, who recently wrote about this story.
Winter: It's just endless photos of a perfect-looking, beautiful family. They're at the park, they're in the swimming pool, they're building snowmen, just smiles and smiles and smiles.
Basu, Narrating: But behind all those social media posts, Lindsay was struggling with mental health issues after giving birth to her youngest child last summer.
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Winter: She was seeking help. She was on online forums talking about anxiety, depression, insomnia, lack of appetite. We also know that she went to at least two different psychiatric clinics seeking help for these symptoms.
Basu, Narrating: Over the course of about four months, Lindsay was prescribed at least twelve different medications. And then, in January of this year, Lindsay allegedly killed her three children, ages five, three and seven months, before attempting to end her own life.
This story is shocking for so many reasons, and it got a lot of attention online. People on social media discussed the case, analyzed Lindsay's online footprint, and tried to just make sense of it all. Jessica told me she got sucked into it, too, and she wanted to understand why. Her best guess is so many mothers can relate to that feeling of being stranded, exhausted and struggling with their mental health after having a baby. How scary, then, to think that Lindsay Clancy might exist somewhere on the spectrum of the postpartum experience.
Winter: There is something horrifying and exceedingly rare, like what happened with Lindsay Clancy, and then on the other end of the spectrum, there are these incredibly common and difficult experiences that we don't talk about.
Basu, Narrating: There's a term to describe the range of disorders that can affect people during pregnancy or after: PMADs. That's "perinatal or postpartum mood and anxiety disorders." Lindsay Clancy was never officially given this diagnosis, but as Jessica explains, PMADs are significantly under-diagnosed and often under-treated.
Winter: PMADs are very common. They affect maybe one in seven birthing people, and they include postpartum anxiety, postpartum depression, postpartum OCD. And postpartum psychosis, which is also a mood disorder, is very uncommon. It only occurs in maybe one or two per thousand births. And it generally comes on in the weeks and months after birth, or perhaps after weaning, if the parent is breastfeeding. It's characterized by mania, auditory hallucinations, voices in your head, delusions, delusional thinking. It's very strongly associated with bipolar disorder. Maybe 50% or more of women who experience postpartum psychosis have underlying bipolar disorder, but they may not know it. This may be the first manifestation of bipolar disorder. That's quite common as well. And although it is rare, you have to take it very seriously because it is one of the most dire psychiatric emergencies that can happen. And that's partly to do with the risk of suicide and filicide associated with it, which is as high as four or five percent.
Basu: You cited that statistic, one in seven people who give birth are thought to have PMADs. And I can tell that there are a couple of very big invisible asterisks there around that statistic. What do we know about how good our data is around this?
Winter: Our data is not good because … It's several different things. There is not good screening for postpartum mood disorders. The American Academy of Pediatrics recommends that for new mothers at all of those pediatric appointments that you have after birth. I mean, you're at the pediatrician all the time in those weeks.
Basu: Sure. One-week check-in, two-week check-in, six-week check-in. Yeah.
Winter: Exactly, exactly. It's recommended. It's not required.
Basu: To check on the parent.
Winter: To check on the parent, to screen them for postpartum mood disorders. And only about half of pediatricians are doing this, according to a recent survey. And of those half, anecdotally, it seems like the screening is often pretty perfunctory. It involves a questionnaire, and there isn't necessarily a whole lot of follow-up.
Basu: And what are the questions that are asked? Like, what do you ask a parent in that moment to screen them?
Winter: I think part of the problem with it is it's temporal. It's kind of: How many times have you felt anxious or depressed in a certain time period? And that postpartum period is such a blur. I mean, time kind of dissolves during that time. [CHUCKLES] Like, what is time during that period? And I think it's very difficult for a new birthing parent to be able to pinpoint all of this. I also think it's really difficult to admit it. I think a lot of people have trouble admitting that they're feeling down, that motherhood or new parenthood isn't this beautiful Hallmark card that they thought it was going to be, or they were told it was going to be. I think, again anecdotally, but a lot of times when new mothers share their anxieties, it's dismissed in a well-meaning way. "Oh, don't be silly." "You're a great mom." "You have nothing to worry about."
Basu: "But look at your healthy baby."
Winter: Yes. "What do you have to complain about?" And those people mean well, and sometimes those people are physicians. [LAUGHS] I can attest to that personally. But it doesn't get at the underlying problem, which is that these feelings and thoughts are real, and the new mother doesn't know what to do with them, and she needs some help beyond these truisms.
Basu: Yeah. Not to mention, you have a big stork in your front yard announcing to everybody. You're sort of expected to be in a celebratory mood with the coming of a baby. And it seems like, not for nothing, you're also at home with a baby all of a sudden that you're taking care of.
Winter: Yeah. You have to present this external picture of maybe not perfection, but at least happiness and contentment. But you're also alone a lot. You're alone at night a lot, up with the baby. It can be isolating, and it can be hard to even find the right moment or the right person to share with, if you do kind of get up the gumption to say something about how you're worried about your own thoughts or you're worried about your own feelings.
Basu: Yeah. I mean, you wrote a bit in this piece about your own experience postpartum, and you shared that while you weren't diagnosed with PMADs, you remember some of those really sleep deprived days and nights and having some really tough mental health moments. You mentioned something called "intrusive thoughts." Can you explain what that is?
Winter: Sure. An intrusive thought in the postpartum period - there's different kinds of intrusive thoughts - but in this period, it's an image of harm coming to your baby. The baby falls down the stairs, or the baby falls out of the baby carriage or something like that. The vast, vast majority of new birthing parents have these kinds of thoughts. And this is the statistic that really shocked me. Fifty percent, at a conservative estimate, half of new mothers have intrusive thoughts of intentionally harming their children. And I think that people confuse those kinds of intrusive thoughts with postpartum psychosis. I've seen a lot of this on the message boards and social media around the Lindsay Clancy case.
Basu: Right. "What does this say about me?"
Winter: Exactly. Intrusive thoughts are not postpartum psychosis. An intrusive thought of harming your child is basically your sleep-deprived, hormone-addled brain, in a clumsy and very unhelpful way, showing you an image of your concern for your child, of your worries about your child. It's a reflection of your loving protectiveness of your child. It's a reflection of your anxieties that something might befall your child. It is not a prophecy. It is not some kind of unearthing of something that you secretly wish to do. It's actually the opposite. That's not that hard to explain, I don't think, but no one explains it to you. And when I had intrusive thoughts, no one explained it to me. And part of the reason that no one explained it to me was that I never in a million years would've admitted it to anyone. And there's good reason for that. Women who have reported these kinds of intrusive thoughts with no intention of acting on them, they've been reported to CPS, they've been reported to the police, all kinds of things have happened. So, there's good reason not to share about these thoughts. So, they're completely taboo. At the same time, one in every two women who are walking into the pediatrician's office or walking into an OB-GYN's office during this period are having these thoughts, or they're going to have these thoughts. And no one talks about it. And I think that was one of the most shocking moments for me in reporting this piece. I think partly because it was personal. If anyone had told me this, it would've helped me so much. And with this piece, I really wanted to get the word out about how common and expected, really, intrusive thoughts are because I think a lot of people will take comfort in in knowing about them.
Basu: Okay. So, just to be clear, intrusive thoughts are not the same thing as postpartum psychosis, but intrusive thoughts can be a part of some PMAD diagnoses, like postpartum depression and anxiety. So, what do we know about what causes PMADs.
Winter: It's not well understood at all. The consensus is that it has something to do with this absolute surge in pregnancy hormones, and then a corresponding plunge in the hormones progesterone and estrogen after giving birth. And there's also a lot of hormonal haywire during the weaning period. So, that's when things can happen as well. There is definitely a social context to PMADs and to how bad a PMAD can get for a woman. If the new parent is really sleep deprived, if she doesn't have someone who can maybe take over a night feeding for her, if she doesn't have that kind of support, that can create a kind of vicious cycle or a feedback loop where the sleep deprivation is feeding the mania that she's feeling. The insomnia is begetting more insomnia, or it's feeding in into the depression, the lowness that she's feeling. A general lack of social support just with everyday tasks. You know, laundry, feeding yourself, handing the baby over so that you can have a shower. These things seem so small, but as they add up and add up and add up over the weeks and months of the postpartum period, they really take their toll. That can also exacerbate the symptoms.
Basu: And it sounds like, I mean, what's so difficult here about all the things you just named is that they are unavoidable. [LAUGHS]
Winter: Completely.
Basu: A lot of them are unavoidable, right? I mean, the laundry is the laundry. And some of those nights are gonna be kind of sleepless nights, at least from time to time. I mean, really, what is the advice to parents?
Winter: There's a paper that I love so much that's literally about prescribing sleep. A bunch of reproductive psychiatrists got together, and they wrote this short, very funny, but very serious paper about how physicians have to talk about sleep like a medication that you can prescribe to a new birthing parent. It makes total sense.
Basu: It makes total sense.
Winter: But as you just said, how do you manage that? You know, when I was breastfeeding my kids, there was just no way I was ever gonna get more than two or three hours of sleep at a time unless I just didn't breastfeed anymore. And so, maybe, you know, I think there's been this gentle push over the years to move away from "the breast is best" conversation. Or to mix a little formula. You know, one bottle of formula late at night that your partner, or a friend, or a night nurse can offer isn't going to completely throw you off your breastfeeding routine. And that …
Basu: Because it just takes such a toll on the breastfeeding parent, really.
Winter: Yeah. Yeah. And I think if we could maybe de-stigmatize a little bit of formula maybe, that would be great. I think that if women could be encouraged, if they don't want to breastfeed, they don't have to. And also, a lot of women go off their depression medications, their anxiety medications. You know, for women with bipolar disorder, they'll go off their lithium while they're pregnant. And that often makes sense. And sometimes, I think, more and more pregnant people are continuing to take their antidepressants while they're pregnant under a doctor's advisement. But you can go back on them as soon as you give birth, as long as you're not breastfeeding. So, I think that maybe we can push a little harder not to make breastfeeding the be all, end all of a quote-unquote "good parent." That could help a lot.
Basu: I'm still stuck on this issue of sleep. [LAUGHS]
Winter: [LAUGHS] Me, too.
Basu: Sleep, when you are a new parent. It's the mental load, the cognitive load of taking care of the baby on top of the literal, physical waking up during the night and being sleep deprived.
Winter: Yeah, absolutely. And your boobs hurt, right?
Basu: Yeah, sure.
Winter: And you're recovering from doing this geometrically impossible thing of pushing this eight-pound entity out of your body. And of course, a recovery from a c-section, in most cases, is way more difficult than the recovery from a vaginal birth. So, you're dealing with all of these things and you're not sleeping, which is literally a form of torture. This is how we torture people. So yeah, I mean, I think that sleep and the interplay of sleep with anxiety and depression and even with psychosis … I mean, a hallmark of postpartum psychosis is that the birthing parent just stops sleeping. It's very common with postpartum psychosis. I completely agree with you that sleep is completely central to the conversation about postpartum health in general and postpartum mental health.
Basu: You know what's tough? I feel like, in some ways, some of these issues have sort of broken through to the mainstream. Right? I think, for example, postpartum depression has become very widely known. I would say even depictions in pop culture in movies and TV shows has sort of helped to raise awareness of a conversation around postpartum depression, really specifically. But a lot of other PMADs, I would say, are still really not talked about, very much sort of treated as taboos, you say in your piece. I also think that there is something very different today than perhaps ever before in the way that we talk about pregnancy and postpartum, a new kind of frankness. I will say among my peers, I feel like I hear a lot of frank talk about how hard it all is, truly how hard it all is. And if anything, I hear a lot of people kind of criticize the glorification of it all. I wonder if that's felt true to you or if that came up at all in writing this piece.
Winter: I think that's absolutely true. I think it's been true for a while. I'm happy that trend continues, but I think that where that trend has hit a wall is in actually getting help for people who experience PMADs. I think that there is this greater awareness of it, there is a greater understanding of it. But it doesn't mean that there isn't, for example, a major psychiatric crisis in this country where there aren't enough psychiatric beds for people who need them. Therapists have these very long waiting lists. I mean, here's one data point for this. "The Washington Post" had a piece recently where they were talking about this crisis. They said that Massachusetts General Hospital, where Lindsay Clancy used to work, at one point last summer, they asked their doctors to stop referring patients for psychiatric care that they thought was non-urgent. They just simply could not triage anymore because they had so many patients who needed help. And so, awareness doesn't fix that. And awareness doesn't fix our managed care system, which is just not equipped to deal with PMADs, to deal with postpartum psychosis, in a way that these disorders are treated in most other industrialized countries that have universal or nationalized healthcare.
Basu: Yeah. You know, as you're speaking, you're reminding me of one of the stories that you wrote about in your piece about a couple, Liz and Brian. Can you tell us a little bit of their story?
Winter: Sure. I met Brian, who is the widower of Liz, and he's the single parent to their young son. And Brian described Liz, and I talked to other people who knew Liz as well, and they all described her as this warm, ebullient, enthusiastic person. A joyful person, a connector of people. She had a lot of strong, loving connections with a lot of people in her life. She loved books and reading. She loved storytelling. She loved to travel. And she was really excited to become a new mom. And shortly after her baby was born, she seemed to become a different person, someone who was detached, emotionless, who seemed not to always have a firm grasp on reality. And not long after her child was born, she attempted suicide. She checked into a psychiatric ward. She was there for about a week. They put her on some medications, they discharged her, she continued to have suicidal ideation. She went into another psychiatric hospital where they gave her different medications and gave her a diagnosis of bipolar disorder. Now, it's my understanding that perhaps no one explained to Liz's loved ones that bipolar disorder and postpartum psychosis have a connection. She was discharged from that hospital, and she died by suicide when her baby was a few months old. And Brian and Liz ostensibly had resources that a lot of people don't. They had good insurance. Brian, in my conversations with him, is such an emotionally intelligent person, who saw the signs that something was wrong and took action and was researching and reaching out and doing everything that he could. You know, even to the point of creating an outpatient plan for Liz. They had a strong family and social network that could help them with meals and transportation and caring for the baby. And yet, right? And yet, this is how it ended. And I think that their story is illustrative of the failures of our managed care, for-profit healthcare system. She only spent a week or two at a time in the hospital. She never spent enough time in the hospital for her medications to take their full effect. Because, under our system, the incentive is to diagnose, stabilize, and discharge. Right? The incentive is not: Keep this person until we know they're absolutely safe. It's just not set up to accommodate that. Our system also does not allow for what most other industrialized countries do, which is mother-infant psychiatric wards. Liz could not be with her baby while she was under care in a hospital. And as Brian explained it to me, this added to everything else she was going through. This added these two major transitions: She had to transition into being away from her baby, and then she had to transition back into caring for a baby full-time.
Basu: Both distressing, I would imagine.
Winter: Absolutely. That doesn't necessarily happen in other countries. Some women just … It's not recommended for them to be with their babies while they're in the psychiatric ward. But according to Brian, in Liz's particular case, this really would've helped her. But it's not a possibility under our managed care system.
Basu: Now, by comparison, you also write about another instance, this one a woman living in the Netherlands, and just how differently they seem to approach care, postpartum care, for a mother in this instance. Can you tell us about her?
Winter: Yes. Her name is Monique, and she has two children. I talked to her on Zoom. And she began experiencing a psychotic episode one morning. No psychiatric history. Doesn't have bipolar disorder. No one could have seen it coming. And it's remarkable the differences between what Brian experienced and what Monique's husband experienced. Monique's husband made one phone call to their general practitioner, who came to their house. Can you imagine, in America, someone …
Basu: Not here. Yeah.
Winter: The GP comes to their house, the GP calls the psychiatrist. The psychiatrist comes to their house, they call an ambulance. They bring Monique and her baby to a psychiatric facility, and Monique is there for three months. And when she is discharged from the facility, she receives nine months of outpatient care, including a social worker, who would come to her house and help her with laundry and groceries and to-do lists and so forth, and help her acclimate to being in a household and being a wife and mother in that context again. And she's obviously spent no time on the phone wrangling with insurance companies or anything of that sort. It's really night and day, the comparison between the two systems.
Basu: You know, this sort of brings us back to Lindsay Clancy's story, which to me feels like a story that's not just about system failures for our medical system, but also system failures for our legal system. Right? In terms of how we think about cases like this, tragedies like this, and what kind of legal repercussions there should be.
Winter: Right. So, most insanity defenses fail, and most insanity defenses involving postpartum psychosis fail. And part of the reason that they fail is that the person charged with a crime has to prove … as a general matter; this varies from state to state. They have to prove either that they didn't know what they were doing when they committed the crime, or they didn't understand that it was wrong. And this has, over the years, proven to be very difficult with judges and juries. The most famous example of a capital murder case involving postpartum psychosis is that of Andrea Yates. She killed her five children in 2001. She lived in a suburb of Houston, and she was experiencing postpartum psychosis. And her conviction was overturned eventually, but she was originally convicted. And two of the factors in her conviction were that she called 911, which indicated that she realized she had done something wrong, and that she waited for her husband to leave the house before she killed the children, as Lindsay Clancy did. Lindsay Clancy did the same thing. She waited until her husband was out of the house. And that showed premeditation, that showed volition. They knew what they were doing. They knew that they had to seize this moment to commit this horrible crime. And again, that is understandable. I understand why people would see it that way. It evinces a misunderstanding of postpartum psychosis. A person in postpartum psychosis, their symptoms, their presentation tends to wax and wane. So, sometimes they will be showing that they're in a psychotic state, and then for long stretches of time, they may seem perfectly normal. They may seem perfectly normal all the time, and this is raging inside of them, and they're able to hide it. And so, I think that you're right, the legal system doesn't really know what to make of insanity cases. But particularly with postpartum psychosis, it's nearly impossible for many women to prove that they did not have volition. And again, on a basic psychological level, you see a woman who kills her children, and that is the ultimate taboo. That is the ultimate unthinkable crime, and it has been since Medea. There's certain, I don't know, reptile brain instincts that we have about such a person, about such a woman, that I think can make it difficult for people to absorb and synthesize everything that we know about postpartum psychosis.
Basu: To cast them as monstrous and so unlike us, right? This sort of desire to separate what someone might be able to do with the feelings that a lot of people might have postpartum.
Winter: Absolutely. And you see this in the response to Lindsay Clancy. It is like this physical pushing away, a banishment of a person as evil. And I think the impulse behind that is to, yes, to differentiate that person from yourself. If you're a person who's experienced intrusive thoughts and you don't understand what a regular-degular intrusive thought is, and you see a case like the Lindsay Clancy case, that's scary, and you wanna push it away, and you wanna disavow it as something that could possibly exist on a spectrum with your own experience.
Basu: I think there's something so eye-level and empathetic about the way you wrote this piece that feels refreshing on this topic, and that you acknowledge is often not the way this topic is dealt with for most people.
Winter: I wrote this piece because I found myself fixated on the Lindsay Clancy case in ways that I didn't understand. I didn't want to be fixated on it. I didn't want to think about it, but I did. And I'm not saying that new parents can empathize with Lindsay Clancy or understand it or see themselves reflected in her experience. I'm not suggesting that at all. What I am suggesting is that these images of harm and anxiety and pain that people commonly experience and the Lindsay Clancy case, there is some kind of magnetic pull between the two of them. There is some kind of resonance there, as far apart as they are. And I think that tension is why I couldn't stop looking at this case, and I think that's why a lot of people can't stop looking at it, even if they want to.
Basu: I think what most people wanna know is when it comes to anything they might be experiencing postpartum, whether that's intrusive thoughts or lack of sleep leading to other things, I think the question that most people just think of is: Is this normal? Is this expected? Or do I need help of some kind? How do people begin to think about finding the answer to those questions?
Winter: I think the onus is really on the patient in ways that it shouldn't. I really came away from reporting this piece believing that physicians need to be more proactive about asking these questions, or not even asking the questions, but just telling the patient, "Here is something that you might expect. Here is something that a lot of my patients have experienced, and you might experience it, too." Because, as we said, it's hard to talk about this stuff. It's scary to talk about this stuff. There might be consequences to talking about the stuff if you tell the wrong person. But if physicians can be proactive and say, "his is what an intrusive thought is. This is what postpartum depression feels like. This is what postpartum OCD … this is how it can manifest. This is something that happened to a patient of mine long ago." Whatever it is, narrativize it, anecdote-ify it. Turn it into a picture that the patient can see. At least then, you're arming her with knowledge. Even if she still doesn't say anything or still doesn't seek help, at least she knows that what she's experiencing … Maybe it's wrong to call it "normal" 'cause it doesn't feel normal to her, it feels terrible. But it's common and there's a lot of people out there. I mean, the way that I think about it since researching this piece is, any mommy-and-me meeting I ever went into, any preschool meet-up I walked into, to realize that half of the mothers and birthing parents in that room, that one out of seven mothers in that room had experienced something like this. It's really changed how I see the world, how I see the parent community at my kid's school. I can just look around and think, "God, there's so many of us." But I didn't know that when it really mattered. And I think that's a shame because there's a lot of systemic, intractable problems with our healthcare system and how we approach postpartum mental health. But a doctor taking a couple of minutes to explain this stuff proactively, I just feel like that's easily fixable.
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Basu: Jessica, thank you so much for such an interesting conversation. I really appreciate it.
Winter: Thank you so much for having me.
Basu, Narrating: You can read Jessica Winter's reporting for "The New Yorker" on Apple News. We'll include a link for you on our show notes page.
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