I. Underreporting of Infanticide and Infant Deaths from Murder:
Problem:
Worldwide infanticide and infant mortality rates are grossly underestimated. Systematic data on the prevalence of infant murder is rare.
Postpartum Support International believes:
Further research and greater accountability for these tragedies will increase public awareness and potential for prevention.
II. DSM4 Diagnostic Criteria:
Problem:
The fact that there are no formal diagnostic criteria for postpartum disorders has significant consequences:
1. The psychiatrist unfamiliar with this literature is less cautious about the unpredictable nature of the psychosis and potential danger to the infant.
2. The expert witness is frequently unaware of the unpredictable waxing and waning presentation of normal mental status followed by florid psychosis in a woman who commits infanticide. This assures inadequate representation in the legal system.
Postpartum Support International believes:
1. Postpartum psychosis (PPP) has unique qualities distinct from non-puerperal psychoses such as affective (usually bipolar) presentation associated with agitation, delirium, bizarre and changing delusions, waxing and waning sensorium and loss of memory i.e. symptoms specific to organic mechanisms
2. Postpartum disorders deserve an official DSM4 diagnostic status which recognizes 1) unique precipitants, namely pregnancy and childbirth, triggered by a neuroendocrine event and 2) psychotic phenomenology associated with organic delirium and cognitive disorganization
3. The benefit of a formal diagnosis is 1) greater education 2) early identification to insure safety for mother and infant, 3) improved treatment guidelines and 4) equal representation for mentally ill mothers in the courtroom
III. American Legislation:
Problem:
A woman with postpartum psychosis who kills her infant may face life in prison or even the death penalty. Because the US courts rely on the DSM4 to “legitimize” a diagnosis, Postpartum psychosis (PPP) and Postpartum depression (PPD) are minimized in the judicial process. Expert witnesses are frequently unaware of the current perinatal literature which is, therefore inadequately conveyed to individual jurors. Most western countries provide leniency and mandate psychiatric treatment through unique infanticide legislation, yet there is no difference in rates of occurrence or prevention compared to the United States. Women with postpartum psychosis need treatment not punishment to deter her from killing again.
Postpartum Support International believes:
1. Defendants with mental illness deserve a defense based on scientific fact
2. Diagnostic guidelines will enhance shared knowledge between psychiatry and the law to focus on prevention and treatment in lieu of punishment.
3. Contemporary neuroscience must be applied to archaic insanity laws by reconsideration of contemporary American legislation.
4. Scientific and biologically based knowledge must be conveyed to the jury so that their decisions can be made on informed facts.
IV. Mental illness and the law:
Problem:
Sentences for women who commit infanticide vary remarkably because insanity laws differ from state to state and lack input from the psychiatric community. Furthermore, the insanity defense used in one half of the United States is based on an archaic legal case (M’Naghton of 1843).
Postpartum Support International believes that
by emphasizing punishment rather than prevention and treatment, the US fails to enlighten society about the impact of mental illness on thought and behavior. We abandon the mentally ill by leaving decisions for treatment and punishment in the hands of the judicial system.
V. Early Identification, Treatment and Prevention:
Problem:
To date, effective strategies for identification, intervention and prevention are glaringly absent from the continuum of antenatal and postnatal care and services. We continue to miss warning signs of tragedy in our most available populations in health care.
Postpartum Support International believes:
Postpartum psychiatric illness is a major public health problem that is predictable, identifiable, treatable and therefore, preventable. Research methodology must be designed to substantiate a cluster of identifiable symptoms for diagnosis to pave the way for treatment strategies and rehabilitation. Antepartum and postpartum screening are optimum times to assess risk for puerperal illness and associated infant morbidity and mortality.