When a Mother Kills Her Children: Postpartum Psychosis With Discussion of the Proposed Melanie Stokes Mothers Act

A 38 year old women drowns here 3 children ages, 3 weeks, 2 and 4 years old and then attempts to kill herself of ingesting lye. She had a postpartum psychosis.
Postpartum or Baby Blues, post partum depression and postpartum psychosis are described as well as the possible causes and treatment approaches to these conditions. Recent efforts to bring about a federal law which would provide education and services with respect to the diagnosis and management of post partum conditions ( Melanie Stokes Mothers Act ) are also discussed.

A Painful Case History *

Several years ago I was called to the hospital to see a 33 year old women who was in the intensive care unit. As I entered the unit with my colleague, a psychiatrist who was training in the psychiatry subspecialty which we now call Psychosomatic Medicine, we noted that there was a police guard at the patient’s door. I reviewed the medical chart which stated that the patient had attempted to kill her self by cutting her wrists and ingesting lye. It also reported the horrifying information that she had drowned her three children ages 3 weeks, 2 years and 4 years old .

The Devil Made Her Do It

As I write this now years later, it is easy to recall the sick feeling I had when I read those words. When we turned our attention to the patient, it was clear immediately that she was completely out of touch with reality. She was hearing voices which she said was that of the devil and he was telling her that he was going to torture her and make her do terrible things. She was very fearful and said she needed to die so she could go to heaven and be with her children. She also readily told us how she had saved her children from the devil and sent them to heaven.

There was some information in the hospital chart which had been obtained from her husband and her minister who told the admitting doctors that she had been a good mother and had attended church regularly. She did not have any psychiatric history although she did have the blues (some mild depressive feelings) after the birth of each of her previous children, from which she reportedly had recovered without any treatment after a few weeks. Her husband had seen that she was again feeling sad after the latest birth of a healthy infant but figured she would get over it as she had in the past. Her sister had recently moved in to the house to help out with the children as the mother hadn’t been sleeping, was complaining of bad dream and was increasingly withdrawn. The sister was out shopping when the patient killed her children and attempted suicide

Postpartum Depression

Will Treatment Make Her Worse?

My junior colleague suggested to me that we could most likely easily resolve her psychosis and her terrified state by giving her antipsychotic medication. I turned to him and said that is when her troubles will really start. “If you think she is distressed now, can you, imagine how she will feel when she realizes what she has really done?” This was, in fact, what happened. We, of course, had no choice but to give her antipsychotic medication over the next several days and also started her on antidepressants. At first she began to think that all her frightening thoughts and hallucination were a bad dream. She appeared to block out what she had done to her children. However, as her psychosis completely cleared she fully understood what she had done. She then became profoundly depressed, spent the day curled up in her bed and had to receive intravenous fluids and nutrition. She still needed medical treatment for her lye ingestion but was expected to recover from it. I saw her almost daily for the next three weeks while she was in the medical hospital. She gradually began to talk with me but there was little change in her self recriminations and her profound grief although she appeared to understand that her actions were a result of a postpartum depression and psychosis. She showed some interest in learning that other women have had a similar condition and this gradually became the one topic about which she was at all comfortable in talking with me.

What Do We Know About Depression After Childbirth?

(The following is a summary of complicated clinical states for discussion in this article and should not be used for make an diagnosis which should be done a qualified physician or mental health professional)

Baby Blues

Baby blues is quite common and is reported in about half of women after childbirth.

It is characterized by mood symptoms but lacks the severity, persistence or pervasive quality of post postpartum depression. The sad feelings that are characteristic can be quite labile. A woman can start to cry for no apparent reason or a seemingly minor one. A more serious diagnosis should be considered when there is difficulty sleeping, a persistent depressed mood, diminished interest in things previously cared about or loss of self-esteem.

Postpartum Depression

The general prevalence of clinical depression in women after delivery is about 13%. Women with a past history depression of depression are at a 30% risk and those who have suffered from a previous episode of postpartum depression have a 50 % risk.

Women with postpartum depression often present with prominent anxiety and obsessive thoughts and behavior characteristically worrying about their baby’s safety or feeding habits and often questioning their own adequacy. In addition there are the usual signs and symptoms of a major depression which include sleep difficulty, loss of appetite, weight loss, persistent depressive mood, diminished interest in things previously cared about, loss of self esteem and even self destructive or suicidal thoughts.

Postpartum Psychosis

Postpartum depression rarely progresses to psychosis which occurs in about 1 to 2 cases per 1000 pregnancies

In such a situation the mother will show evidence of being out of touch with reality. This could be illustrated by having hallucinations, paranoid ideas or other delusions, which are fixed false beliefs. She could be suicidal or have ideas about killing her infant such as in the case history presented in this article or in the widely publicized case of Andrea Yates who reportedly drowned her five children in the similar belief of that she was saving them from eternal damnation. Infanticide is quite rare even in cases of psychosis but obviously can happen.

Just as post partum depression is more likely to occur in women with a history of depression, while I don’t have statistics to support this, I do assume that post partum psychosis will be more likely to occur in women with a history of a major mental illness. However it is important to note the psychosis can be manifested for the first time following childbirth and that it may never occur again.

What Causes These Conditions?

There are many factors that are believed to influence the development of postpartum depression. It is believed that the changing hormonal levels are a factor as might be a genetic predisposition. Co-morbidity with other major mental conditions as well with situations of substance abuse, domestic violence, childhood abuse and other psychological factors can play a role . I look forward to discussing this topic and the latest research in a future blog.

Treatment Approach For These Conditions

Patients with postpartum depression usually respond well to treatment. While initially often frightened by their symptoms, they are usually determined to improve their functioning as mothers and work well with their mental health professionals. Also, often key in the treatment of these women was the use of visiting nursing services and other social agencies in assisting with care of their infants and other children especially in the first few months after delivery. Obviously the support of other family members makes a big difference.

When medication is recommended, patients who understand their need for it are usually compliant and have a good response. Some patients report feeling calmer and less depressed sometimes even before the onset of the expected therapeutic effects of antidepressant medication. There are strategies for prescribing these medications for women who need them even if they are breast-feeding. In those rare cases of psychosis, antipsychotic medication can be effective in bringing about a relatively rapid improvement of those symptoms. At times, a usually brief psychiatric hospitalization is needed

Follow-up with Patient Described Above

The patient described in the beginning of this article was transferred to a special forensic psychiatric hospital unit and I lost contact with her. I feel confident that she was not convicted of murder and would most probably be determined to be under the influence of a mental disorder at the time of her actions.

I have treated many patients with postpartum blues, post postpartum depression and even a few with postpartum psychosis but I have never seen another patient who progressed to infanticide. However I have thought a great deal about this patient.

Can She Go On With Her Life?

When a mother has progressed to a point in a psychotic state where she has murdered her child or children, it may be hard to to imagine that she would recover in any way from that situation. It is easy to say to such a women, that it was not her fault; it was the disease that made her do it. While true, do we believe that she would ever accept this idea and not eternally blame herself? Can she ever go on with her life?

While I have not had the opportunity to follow up with women who have killed their infants, I have had experience in working with people who faced situations that might have seemed to be insurmountable. These have included drivers of vehicles involved in accidents where others have been killed, soldiers who have seen comrades die where they survived, and burn victims who suffered extreme scarring that distorted their appearance in a major irreparable manner, parents who lost a child sometimes in a horrific manner and other equally difficult situations. In each of these cases, while they were deeply psychologically altered, many such persons found a way with psychotherapy and other forms of assistance to resume their lives in a meaningful manner. With some people, it was a religious or spiritual factor that made the difference. In others, it was the presence of other children and loved ones who needed them.

There May Be A Way

There often was still another element that in many cases was an essential ingredient to allow these victims of a tragic situation, to find a way to go on. They found a way to be helpful to others who might have to go through a similar tragedy.

Mothers Against Drunk Drivers (MAD) was founded and developed by parents who had lost their beloved children to drivers who were intoxicated – many of whom may have not no idea that they were too drunk too drive. How many lives were saved by the efforts of this movement and what solace did it provide to these parents to know they saved other children? The work of veteran groups in supporting other veterans and their families is well known. As a consultant to a burn unit for many years , I saw the great value of the members of the Phoenix Society who were burn survivors themselves, in helping struggling patients who were recently burned. There are other examples of such organizations and the work of people in these organizations and individuals volunteering on their own.

Recall, that I mentioned that the postpartum patient I described above had an interest in knowing that other women in the postpartum state had developed depression and psychotic ideas. That understanding might ultimately give her the ability to forgive herself and conceivably even help others to appreciate that this is something that can happen to any women. I hope that she found a way use the experience of this tragedy to do something to make her life worthwhile for herself and others.

Should There Be A Law?

It just so happens that the post partum depression and suicide several years ago of another women, Melanie Stokes, has inspired her family, friends and others to work together and advocate for federal legislation concerning post partum depression. Initially this proposed law was not passed by Congress but it has been reintroduced this year in the 2009 Congress. It was passed by the House of Representative (HR 20) and is due for a vote in the US Senate in the near future.

The Melanie Stokes Mothers Act

This bill known as the Melanie Stokes Mothers Act is not without controversy. The wording of bill is of course subject to change as it is debated. Its stated purpose is to provide education and services with respect to the diagnosis and management of postpartum conditions. The Secretary of Health and Human Services may allow such projects to include providing education to new mothers and as appropriate, their families, about postpartum conditions to promote earlier diagnosis and treatment. The advocates of this bill correctly point out in my opinion that this could save many lives and reduce the hardships and complications of post partum depression. The opponents of it are concerned that grantees would be required to screen all new mothers that they serve. They feel this could bypass informed consent (although any research I ever know of always gives the participant the right to opt out) . They are also claiming that this would lead to an overuse of antidepressant medication and suspect that the pharmaceutical industry is behind this movement. Some of the opponents have claimed that medication used to treat this condition harms women and their unborn children.

Education of Healthcare Workers About Postpartum Depression

As far as I can see this bill does not order specific mandatory testing of women for post partum depression and certainly doesn’t mandate medication. Health care workers who interact with women after childbirth should be educated about the signs and symptoms of post partum depression. Physicians should include an evaluation of the mother’s emotional condition as part of their post partum examination. I am all for these doctors and other healthcare workers to be trained on the latest information on these conditions as part of their Continuous Medical Education (CME).

Depression Chosen As Theme of OB Presidential Year

On May 6, 2009, Gerald F. Joseph Jr. MD of Louisiana became the 60th president of the American College of Obstetricians and Gynecologists (ACOG). Dr. Joseph announced that postpartum depression is the theme of his presidential initiative. He emphasizes the need to develop evidence-based guidelines for ACOG members in the areas of screening, identification, counseling, treatment, referral to specialists and development of community-based resources for women suffering from PPD.

If screening questions have been researched to be valid predictors of these conditions, this information should be readily available to them. Putting specific words or questions in their mouth is not in the tradition of good medical practice. All of this appears to be supported by this proposed legislation.

Role of Antidepressant Medication

As far as the use of antidepressants in women with post partum depression or other types of depression, there is no doubt in my mind that these medications have saved untold numbers of lives and reduced much suffering. The value of them easily outweighs the side effects and occasional adverse reactions, which of course must be fully understood by the treating doctors and their patients.

I welcome your comments on the subject of this blog.

* Personal identifying information and some details have been disguised to protect confidentiality

Review of Fox TV show “Mental”

The Fox TV Network has a new television show this season called MENTAL. The main character is the DIrector of Mental Health Services at a Los Angeles Hospital. In my opinion, the program lacks authenticity and misses the opportunity to depict psychiatry and mental illness in a realistic manner.

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Fox TV Program MENTAL about a  psychiatrist is not an authentic  portrayal of a real shrink

As someone who wants to see the public educated about  psychiatry and mental health, I was hopeful that Fox’s new TV series MENTAL would achieve   the impact and success that Fox’s other series HOUSE has accomplished. Unfortunately after viewing the first 4 out of the projected summer series of 13 episodes, I am quite disappointed.

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Actor Chris Vance

The star of the series is Dr. Jack Gallagher (played by Chris Vance). He is a young, likeable, very smart doctor who is the new Director of Mental Health Services at a Los Angeles hospital ( so far so good ). However, his method of operating doesn’t resemble any real psychiatrist I have ever known or heard about. For example, we are introduced to the main character when he walks into the Emergency Room of his new job and sees a psychotic paranoid man without any clothes menacing everyone. Dr. Gallagher takes off all his own clothes in order to better relate to the patient and talks him down. Not only would a real psychiatrist never do this but even a first year resident should know that such behavior would be viewed as an extremely frightening threat by a patient in this situation.  In one episode Dr. Gallagher is treating a celebrity patient with a Narcissistic Personality and some breaks with reality. The doctor invites a good friend of the patient to view the therapy sessions with the patient through a one way mirror breaking all ethics of confidentiality which are important in all of medicine, especially in psychiatry. In still another episode, a women prosecutor is racked with guilt about people she has convicted. The treatment consists of the hospital staff pretending to be players in a court room drama which the patient thinks is really happening. They plan on reenacting the drama until the patient has somehow worked through her problem. The twists and turns of the various plots appear to be those that people might fantasize that a brilliant psychiatrist in this setting might do, but lack authenticity which would make it much more interesting.

I understand that a successful TV program has to use imagination and take poetic license in its writing. The long-running show ER certainly had complicated character developments and some fanciful plots. However the medical aspects of the program were quite realistic which was an important part of the great appeal of the program. In fact, I believe that one of the reasons that medical students over the past several years have been increasingly choosing emergency medicine as their specialty is because these doctor characters became role models for them. The popular TV show HOUSE showed an eccentric physician with his own quirks but nevertheless just about all the cases were based on scientific thinking and good medicine which also was riveting TV.

It appears to me that the producers and writers of MENTAL either did not have psychiatric consultants or were not listening to them. I know of medical students or medical residents being assigned viewing of ER or HOUSE episodes whereas I can’t imagine asking a trainee to view MENTAL unless it is to see what they should not do. Truth can be more interesting than fiction and there are plenty of clinical books and articles which describe case histories which will make great material for a television shown such as MENTAL.

The National Alliance on Mental Illness (NAMI ) has this show on it’s StigmaBusters alert which means members of this group will be watching and making judgments as to how this program depicts mental illness. Thus far their few comments are mixed. . I certainly share their hope that television shows such as this one will give truthful awareness of mental illness and the battle that patients, families and healthcare providers are going through on the road to recovery. I will be following future episodes to see if they get it right.

Addendum:

I caught some additional programs and I regret to say, in my opinion, the program is not on track to depict mental illness or psychiatry in any where near a realistic or interesting manner. For example one program suggested that a patient’s belief in reincarnation and past lives has somehow connected him to a man who was the lone survivor of a mine disaster almost 100 years ago. Although the psychiatrist in the show says he doesn’t believe in such things, the patient’s belief somehow gave him knowledge of factual things he otherwise couldn’t have known and leads to him having physical symptoms including an episode of a fever of 106 degrees. Even as a far fetched fanciful tale, the story fell flat and it certainly is a big disappointment if it is trying to demonstrate how modern day psychiatrists practice. I can only hope that if this show is renewed and given a second chance next season, the writers will take a close look at some real case histories, which are readily available in textbooks and journals, although perhaps disguised for confidentiality reasons. They will find that truth is stranger and more fascinating that totally made up fiction and that may even help with the all important ratings.

Second Addendum- Program Still Out of Touch with Reality

Since I was a little delayed in launching this first edition of the PsychiatryTalk blog I can report on the season’s two hour finale. Jack hospitalizes his long lost schizophrenic sister and makes the unorthodox and usually unethical decision to try to treat her himself.  He realizes that he was emotionally too involved to be objective and takes the advice given to him and gets some therapy for himself. During a therapy session we  get a glimpse that  one of his problems is that he is afraid of having a psychotic episode himself although he acknowledges that the onset of this condition at his age would be unusual. After a few therapy sessions where we only heard the voice of his therapist, we finally see that his therapist was actually himself . He was really just privately reflecting on things! During the  two hour finale we are also shown two patients with very rare but quite interesting real psychiatric conditions which I will give the program credit for introducing to the audience. One is a man who since childhood has had an intense desire to ampute his own hand. He does it and ends up in the hospital,  Jack recognizes the condition and distinguishes it from the more common type of psychosis. The second patient believes that he has been transformed into a werewolf and is about to kill others seeking blood when the moon comes up. He is holding Jack and some staff members hostage with a gun. Jack convinces the man to bite his arm so they both can face the moonrise together and whatever it will bring. The first season ends with Jack having quit his job at the hospital and is basically going off into the sunset with his guitar case on his back.If this program is renewed, it is hard for me to believe that they will top this season in so far as showing a more unrealistic picture as to what the treatment of mental illness is about . If they should have a second chance,  I sincerely hope that they will give Chris Vance, the talented actor who plays Dr. Gallagher, some better scripts. But of course first they will have to rehire the good doctor.

Depression & Heart Disease

Depression should be considered as a risk factor for heart disease. Potential mechanisms in which depression may act are through blood clotting, heart rate variability and the inflammatory process. Treatment of depression may reduce heart disease and even death from heart disease

 

DEPRESSION MUST BE CONSIDERED A RISKFACTOR FOR HEART DISEASE

In the May 27th 2009 issue of the Journal of the American Medical Association on the Patient Page eight risk factors for heart disease are listed. They are as follows:

  • Smoking
  • High Blood Pressure
  • A high level of low-densitylipoprotein (LDL; bad cholesterol)especially when associatedwith a low level of high-densitylipoprotein (HDL; good cholesterol)
  • High levels of triglycerides (another form of fat found inthebloodstream that can contribute to heart disease)
  • Diabetes
  • Overweight (body mass index [BMI] greater than 25) or obesity(BMI greater than 30)

  • Excessive alcohol use

  • Family historyof premature death (before age 65) from heartdisease.

In my opinion a crucial risk factor was omitted and an opportunity was missed to educate the public about an important approach to limiting heart disease and maybe even preventing death from this killer. There is ample evidence based research for listing depression as a risk factor for heart disease.

POSSIBLE MECHANISMS

Depression  and Blood Clotting

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There is also a pretty good idea as to the physiological mechanisms which connect depression and heart disease. For example, when the platelets in the body are activated a thrombus or clot is formed which can lead to a coronary artery heart blockage and hence a heart attack. Studies have compared this clotting phenomenon in a healthy population without heart disease using both a depressed and a non-depressed group. There was an increase in the clotting activity of the depressed over the non-depressed group.

Depression  and Heart Variability

Another mechanism concerns the HRV or heart rate variability .When the heart is stressed physically or emotionally it has the ability to speed up and slow down depending on the degree of stress. This can be monitored by a 24 hour/day device which can be worn by a person who can keep track of their events. After a heart attack if there is a decreased HRV meaning the heart has3 lost some ability to respond to stress that has been shown to predict potentially fatal heart rhythms. There is also evidence that has shown depressed mood, whether one has cardiac disease or not, is associated with reduced HRV.

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Depression and the Inflammatory Process

In addition, depression has been shown to be characterized by an increase in markers of the inflammatory process, particularly substances known as Interleukin -6 and C-reactive protein (CRP). Both of these factors have also been implicated in bringing about Coronary Artery Disease. However, depressed individuals even without heart disease have elevated levels of these substances. Depression leads to the body producing increased cortisol (the stress hormone) which may produce these inflammatory markers. However most recent research published this month  suggests that there is a genetic link to the production of CRP which may not be connected to heart disease, making these connections less significant.

DEPRESSION AND DEATH FROM HEART DISEASE

Pre-existing depression prior to the development of heart disease is associated with a poor outcome in patients who subsequently develop heart disease and need a coronary artery bypass graft. Not only are such people more likely to die but they are more likely to have prolonged pain and are less likely to return routine activities. There are similar findings in people who have had congestive heart failure. In addition, if there were two people in the intensive care unit after a heart attack with the same degree of damage and one was depressed and the other was not , the depressed person would have a four times greater chance of dying in the next six months than the non depressed patient.

RELATIONSHIP BETWEEN DEPRESSION AND OTHER RISK FACTORS

The connection between depression and heart disease can stand on its own. However, even if you just look at the risk factors listed at the beginning of this piece which were given in the JAMA article mentioned above, we will find a linkage to many psychological factors including depression. In addition, depression is usually co-morbid meaning it co-exists with most other psychological symptoms. Depression also can limit a persons ability to cooperate with treatment, especially with diet and exercise which are often a major component of the recommendations which are made to the person with cardiac risk factors. I will briefly review some of the connections to these risk factors.

Smoking – Often engaged in during times of distress 5including depression. May become part of an obsessive behavior pattern. Leads to addiction to nicotine. Failure to succeed in cessation often leads to depression which causes a vicious cycle

High Blood Pressure Psychological 6stress such as severe anxiety, but also depression, can cause elevated blood pressure especially in individuals predisposed to hypertension.

Diet Related Factors (Inability to control7 proper levels of various types of cholesterol and triglycerides as well as objective obesity)- People with depression often overeat, although individuals with severe depression often have diminished appetite. Obesity can complicate the treatment of hypertension and diabetes.

Diabetes – The issues of diet are intertwined with diabetes and thus with depression. In one study of 6000 people with varying degrees of depression but no diabetes at the start of the study, it was found that 6 % developed diabetes over the next 20 years. Those with high degrees of depression were more than 2 times more likely to develop diabetes. That group was also more likely to be less active, more likely to smoke and more likely to be obese.

Excessive Alcohol Use– Depression and excessive8 alcohol reinforce each other in many ways. The pain of depression can lead to self medication with alcohol in an attempt to relieve such feelings. Alcohol is a depressant to the central nervous system which can intensify pre-existing depressive tendencies. In addition the despair and difficulty in breaking alcoholic dependency can precipitate severe depression.

You need to treat a drinking problem before it leads to worse health problems like heart disease.

( image from: link to freedigitalimages.com )

Family History of Premature Death (before age 65) from heart disease-When a person knows that they have a family history which makes them more likely to have a serious illness such as heart disease at a young age, they often feel as though they are a “walking time bomb”. As they come closer to the age of the expected illness, despair and depression may very well become prominent. George Engel described the Nemesis Complex in this regard related to the dates of heart attacks of his father and then his identical twin

As depression brings about any of the above risk behaviors or exacerbates them, so is the individual more likely develop heart disease and symptoms.

PREVENTION OF HEART DISEASE BY TREATMENT OF DEPRESSION

Good health care would dictate behavior to eliminate any risk factor for heart disease and if possible do whatever you can to modify it. Since I contend that depression is one of these risk factors, treatment of depression is indicated when it exists or when there are precursors of depression such as major emotional conflicts. The type of treatment would obviously depend on the individual and might be psychopharmacology, some form of psychotherapy or a combination of these forms of treatment. In the days when 9tri-cyclic antidepressants (such as Elavil and others) were essentially the main form of psychopharmacology for depression there was the added problem that these medications had significant cardiac side effects. That is not the case with most of the medications used today for depression. In fact there has been some evidence that treatment with the SSRI (Prozac, Zoloft and others) type of medications will normalize the platelet and Heart Rate Variability problems discussed above There is a great deal of experience in treatment of depression in people with existing heart disease without deleterious effects. One of the research projects which demonstrated this is the SADHEART Study. There continues to be ongoing interest and research in this area.

Psychotherapy and medication may also be helpful in treating the other risk factors mentioned which could lead to diminished heart disease.

Finally, remember that depression is a condition that not only is a risk factor for heart disease and other medical illnesses but it is widespread and can be a devastating illness itself. The lifetime prevalence of depression in the general US population is 17.1 %. It is even higher in women (21%). According to the National Institute of Mental Health a suicide occurred every 18 minutes in the United States in the year 2000. It is estimated that at least 90% of completed suicides have diagnosable mental illness, usually a mood disorder. Treatment for depression does work and it can be life saving in more ways than one.

Related Links– Dr. Blumenfield interviews Dr. Lawrence Wulsin about Heart Disease & Depression on “Shrink Pod