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Key points
- Postpartum psychosis is a rare but life-threatening psychiatric emergency requiring immediate treatment.
- Treatment resistance should prompt careful reassessment rather than simply continuing the same approach.
- Patients and families should always be informed and have access to evidence-based alternatives to treatments.
The heartbreaking deaths of three young children in the Lindsay Clancy case have understandably captured national attention. As testimony unfolds, public conversation has largely centered on one question: Was the mother criminally responsible?
That is an important legal question. But from a clinical perspective, another question deserves equal attention: What can this tragedy teach us about identifying and treating severe psychiatric illness before people reach a point of crisis?
When the Brain Becomes Ill
Severe psychiatric illness can profoundly alter the way a person thinks, perceives reality, and behaves. Intelligence, education, professional success, or even being a loving parent do not make someone immune to serious mental illness. Severe psychiatric disorders are illnesses of the brain—not reflections of intelligence, morality, or character (American Psychiatric Association (APA), 2023). It reflects a brain in crisis
Society often assumes that people who are educated, successful, or outwardly “high functioning” would somehow be protected from losing touch with reality. Unfortunately, psychiatric illnesses do not discriminate
Understanding Postpartum Psychosis
The Clancy trial has brought renewed attention to postpartum psychosis, a rare but severe psychiatric emergency affecting approximately one to two women per 1,000 births (Sit et al., 2006; ACOG, 2023). Unlike postpartum depression, postpartum psychosis may involve hallucinations, delusions, profound confusion, insomnia, mood instability, disorganized thinking, and a loss of contact with reality. It requires immediate psychiatric evaluation and, in many cases, hospitalization because the risk of harm to oneself or one’s infant can increase when psychosis is untreated (ACOG, 2023).
Importantly, postpartum psychosis should not become synonymous with violence. The overwhelming majority of women experiencing postpartum depression or other perinatal mood disorders never harm their children or themselves. In fact, sensationalized media coverage may unintentionally increase stigma and discourage mothers from disclosing frightening symptoms out of fear that they will be judged, hospitalized, or lose custody of their children (ACOG, 2023)
When Standard Treatment Isn’t Enough
Another issue highlighted during testimony is one that extends far beyond this individual case: medication- or treatment-resistant depression and psychiatric illness
Although antidepressants have transformed millions of lives, they are not universally effective. Approximately one-third of individuals with major depressive disorder fail to achieve remission after multiple medication trials, often requiring a reassessment of diagnosis, medication strategy, psychotherapy, or alternative interventions (McAllister-Williams et al., 2020)
Some individuals fail to improve despite multiple medication trials. Others experience intolerable side effects or paradoxical worsening of symptoms. Still others require an entirely different diagnostic formulation or treatment approach. Psychiatry, like the rest of medicine, requires individualized care
One medication may transform one person’s life while proving ineffective, or even problematic, for another. Rather than assuming a single treatment pathway works for everyone, clinicians must continually reassess when patients are deteriorating or failing to improve
The Importance of Collaborative Care
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For many patients, treatment is most effective when psychotropic medication is paired with psychotherapy rather than viewed as an either-or choice. Medication can help stabilize symptoms and address biological aspects of psychiatric illness, while psychotherapy helps patients understand their experiences, develop coping and emotion-regulation skills, identify changes in symptoms, and address the psychological and interpersonal factors that medication alone cannot resolve
Research across several psychiatric conditions supports the effectiveness of combined pharmacotherapy and psychotherapy, particularly when symptoms are severe, persistent, or recurrent. Just as importantly, ongoing, and typically weekly contact with a psychotherapist can provide another layer of clinical observation. It helps with identifying worsening symptoms, unusual behavioral changes, suicidality, or possible adverse responses that may warrant rapid communication with the prescribing clinician. Optimal psychiatric care is often collaborative care: the patient, prescriber, and psychotherapist working together rather than in separate silos.
Postpartum Psychosis Essential Reads
The Cost of Misdiagnosing Postpartum Psychosis
The Thoughts Mothers Are Afraid to Tell You About
Expanding the Conversation About Evidence-Based Treatments
One aspect of the current trial has drawn attention to alternative treatment options. Public testimony has indicated that Lindsay raised the possibility of ketamine treatment to her treating psychiatrist. The response she received was that for her to receive insurance coverage for the treatment, she had to fail with four distinct antidepressants. Whether different treatment decisions would have altered the outcome remains unknown and cannot be determined from the available evidence. That question ultimately belongs to the legal process, not speculation.
However, the broader issue deserves serious consideration. Many patients—and even some healthcare providers—remain unaware of evidence-based treatments available for severe, treatment-resistant psychiatric illness. Also, the lack of health care coverage and rigid regulations make it prohibitive for many individuals
Among alternative treatments are:
Electroconvulsive Therapy (ECT): Despite decades of stigma fueled by inaccurate portrayals in popular culture, modern ECT remains among the most effective treatments for severe depression with psychotic features, catatonia, and treatment-resistant depression. In situations where someone is rapidly deteriorating or suicidal, ECT can produce life-saving improvement much faster than traditional antidepressants (APA, 2021)
Ketamine and Esketamine: Over the past decade, research has demonstrated that ketamine-based therapies can produce rapid reductions in depressive symptoms and suicidal ideation for some individuals with treatment-resistant depression. While not appropriate for every patient and requiring careful psychiatric monitoring, ketamine represents one of the most significant advances in depression treatment in recent years (Alipoor et al., 2001; McIntyre et al., 2021)
Transcranial Magnetic Stimulation (TMS), intensive outpatient or partial hospitalization programs, reproductive psychiatry consultation, and multidisciplinary treatment teams may also play important roles depending on the individual’s presentation
The issue is not that every patient should receive these treatments. The issue is that every patient deserves a comprehensive evaluation of all evidence-based options when conventional treatments are failing
The Cost of Delay
One of the greatest challenges in mental health care is that deterioration often occurs gradually. Families may normalize worsening symptoms. Patients frequently minimize their distress. Clinicians may interpret changing symptoms through the lens of an earlier diagnosis. Insurance authorization requirements may delay access to specialty treatments
Each delay may seem small in isolation. Collectively, they can become significant. Mental illnesses evolve. Treatment plans should evolve with them
A Call for Earlier Intervention
The lessons from this tragedy extend beyond the courtroom
- Greater public education about postpartum psychiatric disorders and broader access to reproductive psychiatrists and specialized mother-baby psychiatric programs where available
- Insurance systems that allow clinicians to individualize treatment rather than forcing rigid treatment algorithms when someone is rapidly declining
- Continued research into why some patients develop treatment resistance and how emerging therapies can be integrated safely and effectively
- To remember that psychiatric illness is fundamentally an illness of the brain
Like heart disease or cancer, early recognition and timely intervention can profoundly influence outcomes
None of us can know whether different treatment decisions would have changed what happened in this heartbreaking case. Sadly, the family never got the option to find out
What we can do presently is allow this tragedy to motivate meaningful improvements in education, access to care, early identification, and awareness and access to evidence-based treatment
Lives can ultimately be saved because clinicians, families, policymakers, insurers, and the public become more aware of severe postpartum psychiatric illness and the full spectrum of available treatments. Maybe some measure of change and hope can emerge from this profound tragedy
References
Alipoor, M., Loripoor, M., Kazemi, M., et al. (2021). The effect of ketamine on preventing postpartum depression. Journal of medicine and life, 14(1), 87–92. https://doi.org/10.25122/jml-2020-0116
American College of Obstetricians and Gynecologists. (2023). Treatment and management of mental health conditions during pregnancy and postpartum: ACOG clinical practice guideline No. 5. Obstetrics and Gynecology, 141(6), 1262–1288. https://doi.org/10.1097/AOG.0000000000005202
American Psychiatric Association. (2021). Clinical practice guideline for the treatment of depression across three age cohorts. https://www.apa.org/depression-guideline
McAllister-Williams, R. H., Arango, C., Blier, P., et al. (2020). The identification, assessment and management of difficult-to-treat depression: An international consensus statement. Journal of Affective Disorders, 267, 264–282. https://doi.org/10.1016/j.jad.2020.02.023
McIntyre, R. S., Rosenblat, J. D., Nemeroff, C. B., et al. (2021). Synthesizing the evidence for Ketamine and Esketamine in treatment-resistant depression: An international expert opinion on the available evidence and implementation. The American journal of psychiatry, 178(5), 383–399. https://doi.org/10.1176/appi.ajp.2020.20081251
Sit, D., Rothschild, A. J., & Wisner, K. L. (2006). A review of postpartum psychosis. Journal of Women’s Health, 15(4), 352–368. https://doi.org/10.1089/jwh.2006.15.352
