Months before killing her three children, Lindsay Clancy had asked for help. The Massachusetts nurse had been showing severe symptoms of postpartum depression for months and had called a suicide prevention hotline twice. According to the background presented during the trial, she had also described to a forensic psychologist and a hospital chaplain that she repeatedly heard a male voice ordering her to kill her children and then commit suicide.
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Her mother-in-law, Susan Clancy, also testified. She said that Lindsay had been “crying out for help” during the months before the murders and was going through anxiety, depression, and insomnia.
On January 24, 2023, Clancy killed Cora, 5 years old; Dawson, 3; and Callan, eight months old. She then attempted to take her own life.
Three years later, those preceding months have become a central part of the trial seeking to determine her responsibility. Clancy’s defense, now 36 years old, says she is innocent because at the time of the murders she was suffering from postpartum psychosis that had caused her to lose touch with reality. The prosecution argues the opposite: that she knew what she was doing.
What happened that January 24 is the subject of a trial and it will be the court that determines Lindsay Clancy’s responsibility. But her story, like that of many women, had begun earlier, in those months after childbirth when attention usually focuses on the newborn and the mother’s mental health is relegated to the four walls of her home.
Emily Sliwinski is another woman who has publicly shared how her postpartum psychosis began. In a New York Times article, she described that her thoughts started to go “a thousand miles an hour.” She couldn’t sleep and began having hallucinations in which she believed her dog was talking to her.
Not all women experience the same. Some may start speaking rapidly, sleep very little, or feel excessively euphoric. Others experience distress, confusion, isolation, or depressive symptoms. Delusional ideas, paranoia, or hallucinations may also appear: hearing voices, seeing things that do not exist, or being convinced of something that is not real to others.
And it can all happen very quickly. Psychiatrist Bernardita Lastra explains that postpartum psychosis is rare but considered a medical emergency because “it can take hold very quickly and appear very acutely. Additionally, it is associated with a high risk of suicide and, in some cases, harm to the baby.”
The first symptoms usually appear during the days or weeks after childbirth and can worsen very quickly. “Symptoms can become severe within hours or a few days,” warns Lastra.
At the European Institute of Perinatal Mental Health, various women have shared their experiences after living through postpartum psychosis. One of them, anonymously, said it all began with depressive symptoms that gradually worsened: “I started having thoughts that demons wanted to harm me and my daughter. I wasn’t eating, drinking, or sleeping at all, then I went crazy. I thought my daughter was the demon. The thoughts told me that if I wanted to see my daughter again, I had to harm the demon’s daughter, and I started hitting her.”
That loss of contact with reality is one of the main warning signs. Leslie Ayala, psychologist at the Chilean Perinatal Mental Health Network, explains that postpartum psychosis “requires immediate attention, since the main characteristic is an alteration of reality judgment.”
However, recognizing postpartum psychosis is not always easy. Being rare and having symptoms that can change, it can initially be confused with other conditions that appear after childbirth, such as postpartum depression or the so-called baby blues.
The most important difference is, again, in the contact with reality. “Baby blues is a very common condition that generally does not require treatment, as there is no loss of contact with reality. In postpartum depression, there is persistent sadness, but psychotic symptoms are not present,” explains Bernardita Lastra.
And there is another difficulty. Symptoms of postpartum psychosis can come and go. A woman may be deeply disorganized, have a hallucination, or hold a delusional idea and, moments later, seem lucid and behave apparently normally. That calm does not necessarily mean the crisis has passed. “Often it is not something where a patient can ask for help because there is an alteration of reality judgment. So, it is important that the environment can understand this,” says Ayala.
It is also important to distinguish psychosis from intrusive thoughts, which are relatively common after the birth of a child. A mother may involuntarily imagine that her baby falls, gets sick, or has an accident. These thoughts can be very distressing, but having them does not mean wanting to carry them out or losing touch with reality. “Having an intrusive thought is not the same as having delusional ideas,” explains Ayala. And that difference is important.
There is no single cause for a woman to develop postpartum psychosis. Evidence points to a combination of biological, hormonal, and genetic factors that may influence. After childbirth, the body undergoes significant hormonal changes, in a period often marked by stress, sleep disturbances, and physical exhaustion.
One of those changes is the abrupt drop in estrogen levels. However, psychiatrist Bernardita Lastra clarifies that the problem is not simply that hormones drop, but how some women respond to that change. “There is an individual sensitivity to this postpartum hormonal withdrawal, and that can precipitate a psychotic or bipolar decompensation,” she explains.
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Added to this is something quite common for someone who has just had a baby, which is sleeping little. Sleep deprivation is one of the main triggers and, according to Lastra, often one of the first signs that something is happening.
Among the most important risk factors are personal or family history of bipolar disorder. The relationship between both conditions is close: research has found that between 72% and 88% of women who develop psychosis immediately after childbirth have bipolar or schizoaffective disorder, while about 12% have schizophrenia. More recent studies point in the same direction: in about half of women experiencing a first episode of postpartum psychosis, this is also the first episode of a bipolar disorder.
Psychiatrist Karina Toledo, member of the Chilean Perinatal Mental Health Network, insists that this does not mean there is a single cause. To the stress of having a baby, personal, neurobiological, or immunological factors may be added. “The specific cause is not completely clear, but it is known to be multifactorial and that all these factors combine to generate this condition. That is why it does not happen in all women and is not common,” she explains.
When postpartum psychosis is detected, in Chile it is usual for the woman to be hospitalized. Psychiatrist Karina Toledo explains that, unlike other countries, there are no specialized perinatal mental health units here where mothers can stay with their children while receiving treatment and supervision.
Therefore, often a hospitalization of a few days in a hospital or clinic is chosen and, when possible, home hospitalization continues. The idea, explains psychologist Leslie Ayala, is to treat the condition without losing sight that the woman has just had a baby. “Especially because they have a baby who is sometimes breastfeeding, and the bond is also carefully protected. Despite this, in a person with altered reality judgment, of course there can be a risk because they are not acting from the prefrontal cortex.”
Treatment may include antipsychotic medications, mood stabilizers, and other drugs, depending on each patient. In severe situations or when a rapid response is needed, electroconvulsive therapy may also be used. It is proven that with appropriate treatment, recovery is possible: many women can recover and return to a normal life, although medications should always be accompanied by psychological treatment.
The most acute stage can last a few weeks. “Generally, it can be two to three weeks, during which the patient recovers with treatment, but then requires follow-up,” explains Toledo. This is because controlling psychosis is only part of the recovery; then comes a process that can be equally complex. “Once this stage where psychosis is controlled passes, another very tough stage of reconstruction comes,” says Ayala. Many women do not remember everything they said or did during the episode and must face what happened afterward. “There remains a feeling of trauma, fear that this will happen again, shame, guilt, and difficulty trusting themselves. In addition to the traumas associated with hospitalizations.”
And part of that reconstruction also involves motherhood. “The guilt of this mother must also be worked on, because the fact of having wanted to harm her baby or having been separated from her baby due to hospitalization involves a lot of subsequent psychotherapy work,” explains Ayala.
In this process, the environment is again fundamental. And not only during recovery. Since a woman losing touch with reality may not realize she needs help, those close to her are often the first to notice something is wrong. “We cannot expect a woman losing reality judgment to seek help and ask for it,” says Ayala.
After having a baby, the first check-up established by the public health system in Chile occurs between seven and ten days. It is called the “Diada Check-up” and, as its name indicates, it looks at the mother and newborn together. At this stage, the baby’s development and breastfeeding are reviewed, but also the woman’s physical recovery: vital signs, bleeding, uterine contraction, and how the wounds from a cesarean or episiotomy are healing.
Later, a check-up is suggested at six weeks postpartum, at the end of the so-called quarantine period. At that time, many women also consult about contraception, as they may resume sexual activity. “Postpartum follow-up is not limited to the newborn’s health: it is also essential to support the person’s recovery and adaptation to this new stage after childbirth,” explains Fernanda Cabrera, midwife nurse at APROFA.
However, when it comes to mental health, detecting a crisis can largely depend on the woman herself or her environment recognizing that something is wrong. Both during pregnancy and after childbirth, health professionals apply the Edinburgh Postnatal Depression Scale, a test that seeks to detect symptoms of postpartum depression and other mental health disorders during the puerperium. In the public system, it is applied at two and six months postpartum, as part of child health check-ups. “If warning signs are detected, the necessary evaluation and follow-up should be carried out, including referrals to other professionals when appropriate,” explains Cabrera.
Here one of the main challenges arises. Psychosis usually appears during the first days after childbirth, when the check-ups established in the public system focus mainly on the mother’s physical recovery. Also, a woman going through postpartum psychosis may not have the capacity to recognize that she needs help. “Often, people wait for something very serious to happen before seeking help. So, the environment plays a very important role from a prevention point of view,” warns Leslie Ayala.
Motherhood is usually accompanied by check-ups, recommendations, and care directed at the newborn. But among sleepless nights, physical changes, and new responsibilities, the mental health of the person behind that care can be neglected. Postpartum psychosis is rare, but its sudden nature and severity make recognizing its signs essential. “The birth of a daughter or son implies a change in the place a woman occupies in the world. It is what we call a normative crisis (a transition that requires adaptation), so support, containment, and follow-up are needed.”
And that support also involves how care is distributed. “Unequal distribution of care often means there are no alternatives for the mother to have time to attend a health-related check-up. Therefore, having policies that allow for the mainstreaming of care and support for caregivers is essential,” concludes.
