What is postpartum psychosis? Psychologist explains pregnancy-related mental illnesses

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A tragedy last week in Duxbury has brought postpartum mental health into the spotlight. Lindsay Clancy, who allegedly suffered from postpartum depression, has been charged with a multitude of crimes after the deaths of her three young children at the family’s home. Clancy remains hospitalized with injuries she suffered in an apparent suicide attempt. While authorities have not said whether or not they believe mental illness played a role in Clancy’s alleged actions, similar cases in the past have been linked to postpartum mental health conditions, including postpartum psychosis. Dr. Nancy Byatt, a perinatal psychiatrist at the University of Massachusetts Chan Medical School, joined GBH’s All Things Considered host Arun Rath to describe the differences of pregnancy-related mental health conditions and how they manifest. This transcript has been lightly edited for clarity and length.Arun Rath: Before we get into the conversation, I want to make sure that we’re using terms responsibly here because we’re talking about mental health and we’re talking about a tragic situation. So from from the outset, can you set the terms of the conversation for us? How do we broadly understand postpartum depression and postpartum psychosis? Nancy Byatt: One of the things we hear a lot about is postpartum depression, as you just mentioned. I actually like to think of it as perinatal depression — depression that occurs in pregnancy or within the year after delivery — because depression can occur at any time during that time period. And when we think about perinatal depression, which includes postpartum depression, that is very different than postpartum psychosis, because depression … does not include psychotic symptoms. That’s really one of the main differences. The other illness that increasingly common during this time period is anxiety. More recently, those of us in the field are often using the term “perinatal mood and anxiety disorders,” and that refers to depression during this time period, anxiety disorders, and also it encompasses bipolar disorder.I want to be clear also that postpartum psychosis is very different than mood disorders, and this is very rare. So perinatal mood anxiety disorders overall occur in one in five individuals; postpartum depression or perinatal depression typically occurring one in seven; [and] postpartum psychosis, on the other hand, occurs in one to two in 1,000 individuals. So it’s far less common and much more rare than any of the other mood or anxiety disorders that we see during this time period. When we do see postpartum psychosis, it often occurs in the context of a mood disorder. Primarily, we see it in the context of bipolar disorder. People have episodes of depression with bipolar disorder but we also see episodes of mania, or we can see something called hypomania, and that involves symptoms that are in some ways one could think of it as the opposite [of] depression. With depression, people tend to have low mood, they tend to feel hopeless or helpless. They may have thoughts of death or wanting to die. With mania, it’s quite the opposite. What we see is high mood, elevated energy, decreased sleep a lot, but still with a lot of energy, raising thoughts and irritability.With bipolar disorder, people can have psychotic symptoms in the context of that. When those psychotic symptoms have their onset in the postpartum period, that can be when we see postpartum psychosis. What we see there is psychotic symptoms and that can include hallucinations. So, for example, they may hear voices that command them. And in cases where we see infanticide or suicide, it can sometimes be voices that command people to hurt their baby. The other thing that we see with postpartum psychosis is that people have delusions that are altruistic in nature. So, for example, people may believe that the world is better off without their baby. They may believe that something is wrong with their baby or something’s wrong with them, or perhaps they’ve been possessed or there’s some evil — something evil is happening such that they’re saving themselves and the world from something worse happening, by taking their lives. I think what’s a common misunderstanding with postpartum psychosis is people often ask, “How could somebody do this?” What’s missed is that people actually often do this coming from a place of love and of doing what they feel is best for themselves, for their baby, and even for a greater world or society. Rath: We seem to expect a lot of mothers. And I wonder if one of the effects of that is that does it make it harder for people who are going through this to to seek help? We kind of expect mothers to be able to handle everything. Byatt: I do believe that is a contributing factor. You know, when we think about childbirth, when we think about the parallel time period, it has historically been glorified as this time period in which it’s so wonderful, and mom and baby are so happy. The reality is that it’s not always that wonderful. And in fact, it’s often extraordinarily challenging. … I think because that fantasy or that myth persists, it does make it even harder for people to talk about this, to reach out for help. I also want to add that even when people are comfortable talking about this and seeking help, it’s hard to get help. Many times the mental health care system has a lot of challenges. There isn’t always the capacity for them to respond and be able to provide the adequate response If people are seeking help, or if somebody’s screened in that setting and it’s detected. Rath: I know something we’ve talked about a lot over the last couple of years is how the pandemic has affected the baseline for just about everybody’s mental health. I mean, it’s an environmental issue that affects every aspect of us. How much has the pandemic affected the prevalence of perinatal and postpartum mental illness? Byatt: It has. Certainly we have seen the prevalence of these illnesses increase. I think a few things have happened. One is that the prevalence itself does appear to have increased. So, for example, we used to talk about depression as being more common than anxiety. But more recent studies are showing that anxiety actually can occur in as many as one in five individuals. Depression we’ve always thought of as being one in seven for many years. So, we certainly see an increase in anxiety, which is likely related to COVID. Second, we also are seeing an increased awareness and increased detection, which is a great thing. There has been recommendations from the American College of Obstetricians and Gynecologists and many other professional societies and policymakers to screen individuals during this time period for depression and also, more recently, fringe disorders as well. So with those recommendations, more obstetric practices and providers are screening individuals. So while also detecting this and recognizing it more often than we used to. Rath: Dr. Byatt, it’s been good to talk with you about this and hopefully spread some awareness as well. Thank you so much. Byatt: You’re welcome. It’s a pleasure to be here.

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