The recent tragedy surrounding Lindsay Clancy and her children underscores popular misconceptions about a grave and mysterious disorder.
On August 1st, Lindsay Clancy, a labor-and-delivery nurse at Massachusetts General Hospital, posted to a Facebook group for followers of the “Miracle Morning” self-help regimen, which involves waking up early each day for meditation, visualization, and exercise. “Had my third baby 2 months ago and tried to stick with my MM after he was born,” Clancy wrote. In the previous couple of weeks, she’d fallen off track, but, she went on, “Even though I was up at 12:30, 1:30, and 3 with the baby I’m still gonna try starting my day at 5 so I can get a good MM in before everyone’s up. Wish me luck!!!”
In November, Clancy, who is thirty-two, posted to another Facebook group, called “I Am Not Alone: Postpartum Depression/Anxiety & Rage.” She disclosed that she was experiencing depression, insomnia, and decreased appetite while taking the antidepressant Zoloft; she fared better with Ativan, a benzodiazepine, but worried that she might become addicted to it. In December, Clancy wrote in her journal and confided in her husband about recurrent suicidal thoughts and, at least once, thoughts of harming her children. Just before Christmas, she was evaluated at the Women & Infants Hospital Center for Women’s Behavioral Health, in Providence, Rhode Island, where she was not diagnosed as having postpartum depression. (At some point, Clancy received a diagnosis of generalized anxiety disorder.) On New Year’s Day, she voluntarily checked in to the McLean psychiatric hospital, in Belmont, Massachusetts; she was discharged on January 5th, again seemingly without a postpartum-related diagnosis. Between October and January, according to reports, Clancy was prescribed at least twelve different medications.
On the morning of January 24th, Clancy brought her eldest child to the pediatrician for an appointment. Later that day, she built a snowman with two of her kids in the back yard of their home, in Duxbury, a suburb of Boston; she texted pictures to her husband. Toward dinnertime, Clancy called in a takeout order from a nearby restaurant. Her husband drove from their house to pick up the food and also stopped by CVS, at one point calling Clancy to double-check which brand of pediatric laxative she had asked him to purchase. He was gone for less than an hour. During that time, Clancy allegedly strangled her three children, ages five, three, and seven months, and then jumped from a top-floor window of the house, in an apparent suicide attempt. Clancy was arraigned on murder and assault charges from her Boston hospital bed on February 7th. Her attorney cited overmedication, postpartum depression, and the “possibility of postpartum psychosis” as potential mitigating factors in her defense. (Some of the details of the events leading up to and on January 24th have been drawn from attorneys’ statements during Clancy’s arraignment.)
The tragedy in Duxbury has drawn obsessive attention on Facebook, Reddit, TikTok, and elsewhere, sustained in part by Clancy’s digital footprint, which includes endless photos of Clancy and her children smiling at the zoo, smiling at the beach, smiling in the pool. Some observers have shared their hopes that the case will raise awareness of perinatal and postpartum mood and anxiety disorders, or pmads, which affect perhaps one in seven people who give birth. One of those disorders, known as postpartum psychosis—what Clancy was possibly experiencing—is rare, affecting one or two in a thousand women, at a conservative estimate. Filicide driven by postpartum psychosis is rarer still: the risk is maybe four per cent, although estimates are shaky.
Postpartum psychosis tends to come on suddenly, often within four to six weeks of childbirth, around the time of weaning, or following a period of extreme sleep deprivation; it is sometimes presaged by anxiety and insomnia. A woman experiencing postpartum psychosis may show signs of mania, depression, or both; she may have aural hallucinations, paranoia, or delusions; she may stay awake day and night. She may, for stretches of time, appear to be perfectly normal.
During the arraignment, the prosecuting attorney stressed that Clancy did not receive a pmad diagnosis when she was evaluated in Providence. But pmads are significantly underdiagnosed, and often undertreated even when they have been recognized—one estimate is that only around three per cent of women with postpartum depression are treated to remission. The prosecutor also emphasized evidence of Clancy’s lucidity on the day of the killings: her voice did not sound “slurred or impaired” when she called the restaurant; when she texted her husband about her dinner order, she correctly spelled “Mediterranean Power Bowl.” On social media, where an initial sympathy for Clancy has been largely overtaken by condemnation, these details are deployed as proof that she was sane when she killed her children. But clarity of speech and behavior alone does not rule out postpartum psychosis. “One of the hallmarks is that there’s a waxing and waning of consciousness, confusion, and disorientation,” Lauren M. Osborne, the vice-chair of clinical research in the Department of Obstetrics and Gynecology at Weill Cornell Medicine, told me. “The result is that people with postpartum psychosis may appear fine at one moment and not fine the next moment. It’s that fluctuating course that’s very distinct.”
Although pmads have an obvious triggering event, their neurochemical byways are not well mapped. Researchers suspect a link to the hormones estrogen and progesterone, which surge during pregnancy and plunge after childbirth. Postpartum psychosis is especially mysterious, although it disproportionately affects people with bipolar disorder. Clare Dolman, who is a postdoctoral researcher at King’s College London, received a bipolar diagnosis in early adulthood and took lithium to manage symptoms. She weaned off the drug before she became pregnant with her first child, with no adverse effects. “So I thought, I can breast-feed, because I’ve had nine months or more where I’ve been well,” she told me. Soon, though, she began experiencing mania and hallucinations; after a six-week hospitalization, she recovered. A year later, when Dolman decided to try for another baby, she had a plan: “I went back on lithium as soon as my son was born, I didn’t breast-feed, and I had no problems,” she said. For many women, however, postpartum psychosis is the first-ever presentation of bipolar traits; they lack what Dolman called “the experience and the insight to know that I was becoming ill.”
pmads may also correlate with certain immunological deficits, preeclampsia and other inflammatory disorders, or gestational diabetes. But no one really knows. “Postpartum psychosis has been around for thousands of years, and yet it is not an official disease category in the DSM-5,” Veerle Bergink, the director of the Women’s Mental Health Program at Mount Sinai, told me. “There is no money for it, not for research, not for treatment. There are no guidelines. This is one of the most severe conditions in psychiatry, one that has huge impacts on the mother and potentially on the child, and there’s nothing.”
The presence of postpartum psychosis in medical literature reaches back to the Hippocratic Corpus, from the fifth or fourth century B.C., which described a new mother of twins who suffered delusions and sleeplessness. In “The Book of Margery Kempe,” which appeared at the turn of the fifteenth century and is believed to be the first autobiography written in English, Kempe, a Christian mystic, portrayed her postpartum loss of reason as having brought her closer to Christ. In Victorian England, it was believed that “puerperal mania” or “insanity of lactation” could cause new mothers to imagine harming their infants, or even to act upon these thoughts. The French psychiatrist Louis-Victor Marcé published the first substantive monograph on postpartum mental illness in 1858. “Where subjects are predisposed to mental illness through either hereditary antecedents, previous illnesses, or through an excessive nervous susceptibility,” he wrote, “pregnancy, delivery, and lactation can have disastrous repercussions.”
In the United Kingdom, owing to a law dating from the nineteen-twenties, a mother who kills her child generally receives a manslaughter charge leading to psychiatric treatment, in lieu of a murder conviction or prison time, if the baby is under the age of one and “the balance of her mind was disturbed by reason of her not having fully recovered from the effect of giving birth to the child or by reason of the effect of lactation.” Upward of two dozen other countries have similar statutes; the United States does not. Currently, Illinois is the only state that provides for postpartum mental illness as a mitigating factor in sentencing.
In roughly half of U.S. states, an insanity defense must conform to versions of the M’Naghten Rule, which originated in mid-nineteenth-century England. According to M’Naghten, a defendant must prove either that she didn’t know what she was doing when she committed a crime or that she didn’t know it was wrong. Michelle Oberman, a professor at the Santa Clara University School of Law, told me, “M’Naghten is a standard that doesn’t map onto most cases of maternal filicide” involving postpartum psychosis, owing to its waxing-and-waning cadence. “It’s difficult on a bunch of levels when someone is in and out of psychosis, because, when they’re ‘out,’ there’s a tendency to believe that they have the ability to control when they’re ‘in.’ It starts to look more volitional, and volition is one of the key components of M’Naghten.” Oberman went on, “The legal system is predicated on a binary of sanity/insanity.”
Judges and juries often locate volition even when it seems beyond question that a defendant is psychiatrically disturbed. Kimberlynn Bolaños, a woman in Chicago, killed her five-month-old son, in 2013, in the belief that she was saving him from being kidnapped and tortured; her insanity defense faltered in part because she admitted to feeling regret during the act. In 2015, a California woman named Carol Coronado was found guilty of first-degree murder in the stabbing deaths of her three daughters, ages two, sixteen months, and three months, even though three psychiatrists and a psychologist attested that Coronado was suffering from postpartum psychosis. Andrea Yates, perhaps the most famous American case of postpartum psychosis and filicide, drowned her five children in their home, in suburban Houston, in 2001; she was convicted of capital murder despite a documented history of postpartum psychosis, postpartum depression, and suicide attempts. Two facts were presented as evidence that Yates, per M’Naghten, comprehended that her actions were wrong: she waited—as Clancy did—for her husband to leave the house before killing the children, and she later called 911. (Yates’s conviction was eventually overturned.)
Both the legal and sociocultural responses to these cases, Oberman told me, tend to cleave to race and class lines. “A necessary though often insufficient condition for an insanity defense may well be that you are wealthy enough to have a documented mental-health record: you talked to doctors about it—you had the resources to seek treatment,” she said. “This may be why most of the people who successfully exonerated themselves on grounds of postpartum psychosis have been white and affluent.”
One of these people was Angela Burling, who was found not guilty by reason of insanity at the 1984 manslaughter trial, in California, for the death of her nine-month-old son, Michael, her second child. Burling, who was married to a lobbyist for the California prison union, believed that her husband was the second coming of Christ and that Michael, whom she was weaning, was the devil. “It was an unravelling of my mind, but it felt real,” Burling told me. “Everything spoke to it: the radio, the television, seeing balloons for the grand opening of a new store—I thought, Oh, they must be celebrating the second coming of Christ.” She drowned Michael in a bathtub, convinced that her husband would raise him from the dead after three days. Prior to Michael’s death, she said, there were few outward signs that she had entered postpartum psychosis. “I was grocery shopping, feeding the children, giving them bottles, changing diapers, reading to them,” she said. “If you’d looked at me closely, you might have seen it in my eyes—just dazed. My husband did say at one point that I seemed quiet.” She can retrieve an image of the ordinary morning of her son’s death: her husband leaving for work, “and Michael had his Cheerios on his little tray.”
In our conversation, Burling said that her race and class undoubtedly boosted her legal defense, as did medical records showing that she had suffered a psychotic episode after the birth of her first child. Race and class also guide how much and what kind of attention these cases receive. In September, Erin Merdy, a Black woman in Brooklyn who was struggling with mental illness and facing eviction from her apartment, allegedly drowned her three children, ages seven, four, and three months. In November, Dimone Fleming, a Black woman in the Bronx who had reportedly become fixated on demonic possession, allegedly killed her sons, ages three and eleven months. In December, Paulesha Green-Pulliam, a Black woman in San Francisco who had recently lost a baby boy during childbirth, allegedly killed her daughters, ages five and one. All three women have been charged with murder. Unlike the Clancy case, none of these incidents became major national news or fodder for numerous lengthy Facebook and Reddit threads. The father of Merdy’s eldest child, following his death, started a GoFundMe in his son’s name; it raised about eight thousand dollars of its fifteen-thousand-dollar goal. The GoFundMe for Clancy’s husband has raised more than a million dollars so far.
It is not surprising that an upper-middle-class white woman who commits filicide would receive more attention than a poor Black woman who does the same; the imbalance is a variation on “missing white woman syndrome.” But why do people fixate on these ghastly cases at all? Why does a single Facebook group devoted to discussion of the Clancy killings have nearly sixteen thousand members? It is more than mere fascination with the grisly and sensational; it is also, I think, a way of surfacing experiences that many of us—in far milder ways—share, and cannot otherwise talk about.
In the middle of one night eight years ago, when my daughter was an infant, I was nursing her on our living-room sofa when a hulking blur loomed in the corner of my eye. I turned toward the nursery, adjacent to the living room, and saw, for a single billowing moment, a giant floating baby—a kind of Mylar-balloon version of my own baby—hovering in the doorframe. I knew it wasn’t real, yet there it was. Two years later, in the middle of much the same night, swaying on the floor of the same nursery while holding my infant son, I felt a hard yet yielding pressure just below my shoulder blades, like the heel of a hand against my back. I thought I had bumped into the door to the room, which was ajar, but when I turned, the door was shut, and nowhere near me. A few nights later in that room, I sensed a hand on my shoulder that wasn’t there. A ghost, or something like a ghost, was in the room with us. I felt this to be true, and I knew it was not true. To this day, I can be tidying up or folding laundry in that room and realize how accustomed I am to the possibility that I’m not alone in it.
I chalked up these episodes to extreme sleep deprivation, found them funny, and told a few friends about them. There was something that I did not tell my friends, that I never told anyone until I was researching this piece, and that I never even attempted to Google, because what if someone found it in my search history? When both of my children were infants, the same image flashed inside my eyes several times a day: that by some spasm or seizure or uncontrollable urge I would throw the baby against a wall. The image was blurry, monochrome, sped-up, a squiggly pencil animation that instantly erased itself. Outside of the flash, I felt no fear that I would actually hurt my child. But I was frightened and ashamed that my brain could produce such an image at all, and that it found the image so irresistible that it would keep cueing it up, like a catchy song or a cherished memory.
These images are known as intrusive thoughts, and they are about as ordinary in the postpartum period as lack of rem sleep or mastitis. The vast majority of new mothers have unwanted thoughts about their infant being harmed, and around fifty per cent of postpartum people have thoughts of intentionally harming the baby themselves. (A nasty cousin to the intrusive thought is postpartum parasomnia, such as the “baby-in-bed” waking nightmare, in which the half-awake mother searches frantically in the bedsheets for her lost infant.) “Intrusive thoughts have a pretty sensible evolutionary function,” Osborne told me. “ ‘My goal as a mother is to protect this vulnerable being. I need to be aware, at every moment, of any harm that can come to the child.’ If you combine that with an American society that says that the mother is to blame for everything, then you have an evolutionary reason and a societal reason for people to have these thoughts.”
Wendy N. Davis, the executive director of the nonprofit Postpartum Support International, told me, “We’re talking about a picture of fear, not an urge, and not a lack of skill. In fact, the parents who have these unwanted thoughts tend to be vigilant, highly attuned parents. They’re not at risk of harming their children.” Davis went on, “I know a mom who scooched down the stairs on her butt for four months with the baby, because she kept seeing—not wanting to do it—but she kept seeing the baby go over the railing.”
Seriously depressed birthing people who have intrusive thoughts, Davis went on, are at a higher risk for suicidal ideation and suicide, “because their brain is saying, ‘This baby will be better off without me.’ ” Intrusive thoughts can also interfere with what little sleep a new parent is getting. “If you have intrusive thoughts that your baby’s going to die or something awful is going to happen, that may prompt you to check on the baby constantly, or make it hard for you to trust other people with your baby,” Khatiya Moon, a reproductive psychiatrist at Northwell Health, told me. “It becomes exhausting and it feeds into that depression and anxiety that people may already feel.” For mothers who are predisposed for the development of postpartum psychosis, Moon said, “Poor sleep is a huge risk factor.”
I believe now that if I could have told someone about the intrusive thoughts, I would have had fewer intrusive thoughts. (Getting some sleep, a virtual impossibility during the first couple months of breast-feeding, also would have helped.) Putting words to the thoughts might have summoned the psychic garbagemen to clear the garbage out of my brain. But there are good reasons to say nothing. Women who have told medical providers about their intrusive thoughts, but who did not act on them or intend to act on them, have been reported to the police, have been investigated by child-protective services, and have even lost custody of their children. One woman claimed that she became the subject of a C.P.S. investigation because she blogged about having postpartum depression.
Why would a psychiatrist or an ob-gyn physician or nurse call the police to report a patient for their thoughts? Part of the answer might be found in the void between psychiatry and obstetrics. “Training about reproductive psychiatry is not required in psychiatry-residency training—you can graduate knowing zip about reproduction,” Osborne said. Likewise, ob-gyn residents are not required to receive training in initiating treatment for a patient’s anxiety or depression. In 2019, the American Academy of Pediatrics recommended that pediatricians screen birthing parents for pmads at the one-, two-, four-, and six-month well-baby visits; a 2019 survey showed that only about half of pediatricians were doing so. “Some pediatricians say, ‘I’m not the mom’s doctor; I’m the baby’s doctor,’ ” Osborne said.
The intrusive thoughts that I experienced have little to do with the delusions and disassociation native to postpartum psychosis. As disturbing as the thoughts were to me, they likely wouldn’t have met a threshold for diagnosis of postpartum anxiety or depression. The paradox of intrusive thoughts is that they are at once taboo and utterly banal. This is a great clue, I think, to why Lindsay Clancy’s case has attracted such unrelenting attention on social media. Most of the commenters on Facebook and Reddit appear to be mothers; it follows, then, that half or more of them have had intrusive thoughts that they didn’t act upon. They likely don’t know, just as I didn’t, that it is common and normal for the hormonally askew and sleep-starved postpartum brain to crank up a projector full of cautionary horrors, just as it is extraordinarily uncommon and abnormal for the brain to generate a wholly different kind of horror and to interpret it as a command. The juxtaposition of the unspoken and the unspeakable is why so many people cannot look away, even if they want to. Lindsay Clancy is the intrusive thought.
Postpartum psychosis and other postpartum mood disorders tend only to earn serious media investigation when the death of a child is involved. But the greatest physical and psychological risk posed by these maladies, of course, is to the mother. The last trip that Brian, a teacher in New York City, took with his wife, Liz, before they had a baby was to the Olympic Peninsula, in Washington State, where they passed through the small city of Port Angeles. A crosswalk on the main street is supplied, on either side, with large red flags, which pedestrians are encouraged to hold up and wave as they cross the street. “I thought, That’s ridiculous, but Liz’s instinct was, We have to do that and we have to take a video of ourselves doing that,” Brian told me. “So I did it. I was so happy whenever she brought me out of my shell, and I was sure that she would do that as a mother—to be goofy, to encourage our child to be himself, to embrace embarrassment.” He knew that Liz, who worked in the publishing industry, would pass on her love of reading and storytelling to their child, whom they named Owen. She would teach him to write plays and poems. From Liz, Owen would learn friendship and socializing; he would inherit her emotional intelligence; he would learn the art of being goofy.
I met Brian at his apartment one afternoon in February, just as the local elementary school was letting out. Within a few weeks of Owen’s birth, Brian told me, Liz had become detached and emotionless. (I am withholding their last names.) Brian said, “She had a warmth and empathy that could bring those things out in me—I didn’t necessarily have as much of that when I met her. She made everybody feel like they mattered, and she really believed that they did. She approached life with joy, and all of a sudden the joy was missing.” He told me that Liz struggled with breast-feeding and did not sleep. “She had an unstable hold on reality,” he said. “She told me that she felt like she wasn’t in reality but was just watching it from far away, with no feelings.” At times, according to Brian, this sense of alienation intermixed with feelings of guilt and failure as a mother. “She was unable to pull out of spirals of self-doubt,” he said.
About two months after Owen’s birth, Liz attempted suicide. She then spent about two weeks in a psychiatric ward. By that point, Liz had a diagnosis of postpartum depression, and was being treated with Zoloft, the antidepressant, and Abilify, a mood stabilizer commonly prescribed for bipolar disorder and schizophrenia. “It was pretty clear that it was a revolving-door situation there with the patients,” Brian said. “The doctors were, like, ‘We are looking for drugs to solve this problem. We can’t even begin to get to the bottom of someone’s feelings—we are just trying to regulate here.’ That was my understanding of their approach.” Brian was making calls and doing research, trying to come up with an outpatient plan for Liz. The crowded psych ward “wasn’t an environment that was conducive to feeling better, and it continued the detachment because she was away from Owen,” Brian said.
After she was discharged, Liz began spending time at a facility that provides supportive services for people affected by pmads. Within about a week, however, Brian discovered that Liz was searching online for information about suicide. She was admitted to a psychiatric hospital upstate, where she received a diagnosis of bipolar disorder. “The doctors said that pregnancy turned the switch on,” Brian said. Liz began taking lithium, a mood stabilizer commonly prescribed for bipolar disorder, and Zyprexa, an antipsychotic medication. As long as Liz was in the upstate hospital, Brian could rest assured that she was safe, and he could focus on caring for Owen. But, he said, “once they decide a person isn’t suicidal anymore, the insurance cuts you off.”
After about three weeks, around the time that the new school year was starting, Liz was discharged from the hospital and began outpatient services again. On the recommendation of her medical team, she was spending incrementally more time on her own at home. One morning, Brian and Liz dropped off Owen at day care together; Brian continued on to work and Liz returned to their apartment. “That’s when it ended up happening,” Brian said. Liz took an overdose of over-the-counter sleep medication and died days later.
Liz had access to health-care providers, good insurance, and a proactive and observant partner. But, at crucial times, her treatment was shaped by what my colleague Rachel Aviv, in her book “Strangers to Ourselves: Unsettled Minds and the Stories That Make Us,” calls “the dictates of managed care: patients must be diagnosed, prescribed medication, and discharged within a few days.” The rapid turnaround isn’t compatible with some of the antidepressant and antipsychotic medications typically prescribed for pmads, which can take several weeks to fully kick in. And, unlike many countries—including the U.K., Australia, India, and throughout Europe—the U.S. does not have mother-baby inpatient psychiatric units, because insurers will not cover the hospital admission of a healthy infant. The separation of mother and child, Brian said, necessitates “a huge transition that there’s no way to prepare for.”
Although Brian and Liz had the loving presence and support of family and friends throughout her illness, the couple had little institutional guidance. Without medical or psychological training, Brian had to research and arrange for a battery of interventions, manage insurance paperwork and transportation, and, at times, closely monitor a patient at risk for suicide, while holding down a job and caring for an infant. Like almost anyone, he knew little to nothing about pmads, about the effects or drawbacks of various medications Liz was taking, or about the relationship between bipolar disorder and postpartum psychosis. “I just saw the symptoms and wanted Liz to get better,” he said.
In my conversations with Brian, I kept thinking of Monique van den Eijnden, a mother of two near Amersfoort, in the Netherlands. I had talked with her on Zoom a few days before I first met Brian. On a June day ten years ago, van den Eijnden woke up earlier than usual. She dressed her two-year-old son, four-month-old daughter, and herself. Later that day, she asked her husband and kids to stay on their living-room couch, because “dangers” had sprung up on the other side of the house—a swamp, a magical well. Her husband called a general practitioner, who came to their house and called a crisis line; the crisis service in turn called a psychiatrist to the home. Eventually, an ambulance transferred van den Eijnden to a mother-baby unit in a psychiatric ward, where her youngest child soon joined her.
“It was as if every drawer was pulled open in my head,” van den Eijnden told me. “I thought my dead grandmother was in the hospital, so at night I went from room to room looking for her, knocking on doors. I thought I was in a museum in Berlin. I was speaking French. I thought I was hooked up to other people with threads everywhere, like in ‘The Matrix.’ ” Van den Eijnden responded poorly both to sleep medication and to antipsychotic drugs. Because she wandered at night, doctors moved her to a more secure isolation room; her husband took over caring for their baby, using paid leave. Hospital workers later found van den Eijnden attempting to breast-feed a pillow.
She spent around eight weeks in the lockdown ward, moving between psychotic and catatonic episodes, and eventually recovered with the help of electroconvulsive therapy. After about three months in the hospital, van den Eijnden received nine months of outpatient treatment. She received home visits from a social worker to help her reacclimate to running a household—assistance with to-do lists, laundry, and the like. She also tapered off lithium, under a doctor’s supervision.
During her last weeks in the psychiatric hospital, as van den Eijnden was emerging from her cycles of psychosis and catatonia, she told me, “I felt more like a child myself, as if the world was new and I had to discover everything again.” A pivotal day, she said, was one when her family visited. They gathered in a meeting room in the mother-infant unit, with its mild beige-and-yellow color scheme, play mat, and changing table. Her husband came in with their baby on one arm and their toddler holding his other hand. It took van den Eijnden a few moments to understand that these kids were her kids, that she was their mother. “It was as if I was seeing them for the first time,” she said. “I was amazed by how beautiful these children were.” ♦
