Margaret Spinelli, MD is an Associate Professor of Clinical Psychiatry, Columbia University College of Physicians and Surgeons, Director of Maternal Mental Health Program, New York State Psychiatric Institute, and an expert witness for the defense at Andrea Yates’s retrial.
In my last year of medical school at Cornell University Medical College, I spent a 2 month clinical clerkship at the Maudsley and Bethlem Royal Hospital in London. I was placed on one of the mother-baby units. The United Kingdom was my door to the field of perinatal psychiatry (psychiatry associated with childbirth), a field almost unknown in the United States in the 1980s. Yet I was keenly aware of the need for such services, having been an obstetrical nurse for 15 years prior to my career as a physician.
The United Kingdom, Australia, Canada and Europe have been years ahead of the United States in research and treatment of these illnesses, all having mother-baby units. These are psychiatric units where mothers with postpartum illness are admitted with their babies for treatment. In these units, mothers continue to bond with their babies while they are treated for their illnesses. Parenting and infant massage classes play a prominent role in the therapeutic process.
Although the past 10-15 years have seen a growth of research in the United States, education of families and the public is still severely lacking. In addition, education about perinatal disorders is often not part of medical education. In recent years, obstetricians and pediatricians have become more aware of the psychiatric illnesses associated with childbirth. Without this education, the early identification necessary to provide timely treatment is impossible.
Maternal mental illness not only impacts the mother; it has adverse effects on the infant as well as the family. Most of all, it impairs the emotional well-being and development of the child. Mothers who are depressed do not respond well to their infants’ cues. Early identification through education is the key to discovery and treatment.
In this piece, CBS Cares has given me the opportunity to share some of our current knowledge in the field of women’s mental health. In order to do this, I have answered some general questions and offered information including case vignettes and methods of early identification and prevention of postpartum disorders.
What is the difference between postpartum “blues” and postpartum depression?
Postpartum “blues” is not depression. It is a period of mood “ups and downs” that occurs in almost every woman after birth. It may last for 10 to 14 days. And even though worsening signs should be monitored for depression, it often abates. The symptoms include feeling overwhelmed, anxious, having difficulty sleeping and feeling elated one minute, then crying the next.
Postpartum depression is a major public health problem affecting 10-20% of all childbearing women. It can occur in the first weeks or months after childbirth. The symptoms include persistent sadness and crying, feelings of guilt and inadequacy about what they see as their poor mothering skills, inability to sleep even when the baby sleeps, over-concerns about the baby, anxiety, inability to bond with the baby or even thoughts of suicide.
Sometimes new mothers can be tortured by obsessional thoughts about hurting their babies, but do not want to hurt them. For example, one woman kept having images about knives and killing her baby. These images can occur over and over again throughout the day. She became so frightened of them that she discarded all of the knives in the house and sat outside of her apartment every day with her baby until her husband came home. This must be differentiated from the woman who is psychotic, who may be hearing voices or feels she is under the command of something telling her to kill her child. Psychotic women can act on their thoughts because their thoughts may become their reality.
Who gets postpartum depression?
While postpartum depression may be a first episode of depression for some women, it is most prevalent in women who have had a previous history of depression or have a history of depression in their family. One of the strongest predictors of postpartum depression is depression during the pregnancy. Fifty percent of depressed pregnant women will have a postpartum depression; therefore, pregnancy is the optimum time for treatment and prevention. Obstetricians, pediatricians and primary-care physicians have become increasingly knowledgeable about identifying these disorders in their pregnant and postpartum patients.
What is antepartum depression?
Antepartum depression is depression that occurs during pregnancy. Once thought to be a time of “bliss” for the mother, we now know that more than 10% of pregnant women will have a depression. Furthermore, one half of these women will continue to be depressed in the postpartum period. This emphasizes the need and potential benefit of early intervention. Because the new mother is expected to be unfailingly happy, the stigma of mental illness is even more pronounced at this time in a woman’s life. Not surprisingly, she often keeps secret any thoughts and feelings of guilt and failure she has experienced.
Because the pregnant depressed woman may be less likely to eat, sleep or tend to her prenatal care, the fetus may be placed at risk. Again, the optimal time for early identification is during the prenatal period.
Do hormone changes at birth really affect your mood?
Childbirth is a physiological event that creates profound changes in the body’s equilibrium. Over the period of pregnancy, hormones become extremely high (some up to 200 fold). At the time of delivery, the hormones plummet to very low levels within 24-48 hours. Because the hormone changes can disrupt brain chemistry, psychiatric symptoms may be the consequence. In addition, the time of childbirth is one of great stress for the new mother with disruptions in her sleep cycle, new responsibilities and a new role.
What is postpartum psychosis?
First, postpartum psychosis is not postpartum depression. Psychosis is a loss of contact with reality demonstrated by hallucinations (hearing voices or seeing things) and delusions (false beliefs such as believing one is God). The diagnosis is rare, affecting 1/1000 women. Most cases of postpartum psychosis are episodes of bipolar disorder (manic depression). Women with bipolar disorder are at the highest risk for a postpartum psychosis.
When psychosis is present, delusions and hallucinations become prominent. The woman might feel “taken over.” It is therefore a psychiatric emergency. The woman must be separated from her baby because her actions are unpredictable and she may not have control over them. The following vignette describes such a case: I received a call one evening about a patient in the emergency room. Patient A was a nurse who was 3 weeks postpartum. She was psychotic and had tried to cut her wrist. The doctor on call wanted to send her home. I disagreed and suggested that she be admitted. When her brother walked into the emergency room, she attacked him, which luckily assured that she would be admitted.
Several weeks later, after treatment when she was no longer psychotic, she described what was going on in her mind. All of her delusions were circumscribed around the number “3″. That night every car she saw had 3 headlights; her labor was for 3 hours; she was 3 weeks postpartum; there were 3 voices in her head that said she must sacrifice 1 of 3 generations — her mother, her new infant or herself. It was at that time that she decided it must be her and cut her wrist. Her mother walked in just in time and brought her to the emergency room.
Unlike other causes of murder, infanticide has known and identifiable precursors, namely pregnancy and childbirth. It is therefore predictable and preventable. In my book, Infanticide: Psychosocial and Legal Perspectives on Mothers Who Kill (American Psychiatric Publishing, 2002), I have attempted to educate the public and professionals about perinatal illness as it works its way from the mental health system to the criminal court system. This statement is an overview of my book.
The “Tragedy” of Andrea Yates
In June 2001, the country was riveted when Andrea Yates drowned her five children in the bathtub of her Houston, Texas home. Perhaps no other case of infanticide (murder of an infant < 1 year) or filicide (murder of a child > 1 year) demonstrates the paucity of our medical and legal knowledge and understanding of postpartum psychosis and associated infanticide.
Andrea Pia Yates was a devoted mom who home-schooled her children. She remained pregnant and/or breastfeeding over the course of 7 years. Mrs. Yates had a history of psychiatric illness and a first reported psychotic episode after her first birth in 1994. She told no one because she feared Satan would hear and harm her children. Two suicide attempts after her 4th pregnancy were driven by attempts to resist satanic voices commanding her to kill her infant.
Six months after her 5th child, Andrea Yates became almost mute and walked around the house like a “caged animal.” After two psychiatric hospitalizations, she continued to deteriorate. When her psychiatrist discontinued her antipsychotic medication, she became severely psychotic. She stated that Satan directed her to kill her children to save them from the fires and turmoil of Hell. This time she could not resist.
Infanticide; vulnerability or culpability
Mrs. Yates was charged with capital murder. Although Andrea Yates pled innocent by reason of insanity, the prosecution asserted that she knew right from wrong at the time of the killings because she called 911 and her husband after the killings. The prosecutor elected to give her the death penalty if she was found guilty. Before the verdict came in, it was determined that the prosecution’s psychiatrist gave false testimony. Although Mrs. Yates was found guilty, she was sentenced to life in prison, then a mistrial was declared. Mrs. Yates was granted a new trial in July 2006. This time she was found not guilty by reason of insanity and was mandated to a psychiatric inpatient unit.
In England and Wales, a woman who has killed her infant under a year can be indicted for infanticide, which is a crime equal to manslaughter. The legislation, which provides for this charge is contained in the Infanticide Act; in women with mental illness, treatment and probation are mandated in both countries. Scotland has no such provision, yet rates of infanticide and features of victims and perpetrators are similar in the three regions. Twenty nine other European countries, as well as Australia and Canada, also have infanticide laws, which make infanticide a less severe crime with less severe penalties.
After 80 years of using probation and treatment in lieu of incarceration, the British legal system has demonstrated that this method is as effective at preventing or deterring infanticide as is incarceration, while being considerably more efficient and cost-effective.
In the United States, a woman with severe mental illness who has killed an infant is charged with homicide. If convicted in the American judicial system, she may face a long prison sentence or even the death penalty. Due to the scarcity of psychiatric treatment in our overcrowded prison system, these women exit the system in their childbearing years with the same psychiatric symptoms that brought them into prison.
The question then to ask ourselves is what we seek to gain by this punishment and how can we prevent these needless tragedies in the future?
The fact that the insanity defense is non-existent in some states and extremely limited in others speaks to our disregard for mental illness and the rights of those who suffer. Until we treat mental illness with the same dignity afforded to other illnesses, the course will remain unchanged.
What can we learn from the Yates tragedy?
A series of errors paved the way to the tragic events of June 20, 2001 when Andrea Yates drowned her children. The following represent warning signs or missed opportunities for prevention:
Personal history of psychiatric illness: Mrs. Yates had a series of depressive episodes from the time of adolescence. She had one episode after her first child was born in which she heard a voice saying that she should stab her baby. Mrs. Yates then had 2 psychiatric hospitalizations after her 4th pregnancy, both for psychosis and suicidal ideation. After her 5th pregnancy she also had 2 hospitalizations.
Family history of psychiatric illness: Mrs. Yates’ brother had bipolar disorder. Her father, sister and brother had depression.
Family denial, ignorance or fear of stigma: Family members described her as mute; staring for hours and scratching bald spots into her head to show “666″ or the sign of the beast. Mr. Yates described his wife as withdrawn because of her father’s death, and seemed to minimize her deterioration.
Environmental and social factors: A rigid belief system seemed to dominate the home and family. The couple had come under the influence of a self-proclaimed minister who preached about Satan. These beliefs fed into Mrs. Yates psychosis.
Isolation: Andrea Yates home-schooled her children and had little interaction with neighbors and friends.
Increased number of children: Mrs. Yates had 6 pregnancies and 5 children within the years 1994-2000. One pregnancy was a miscarriage. In addition, she was also breastfeeding between each pregnancy and even during pregnancy. This disruption in the hormonal environment had powerful effects on her mental status. Her hormone status had no time to re-establish equilibrium.
Family and child services intervention: During a 1999 hospitalization, Mrs. Yates reported to the staff that she was overwhelmed living in a converted Greyhound bus with her growing family of 4 children, 3 of whom slept in the luggage compartment. Mr. Yates told a social worker that he was training his sons including the 3-year-old to use power drills. The social worker filed the report with Children’s Protective Services but the state agency declined to pursue the case. The psychotic mother was sent home to care for her children on her own.
Inadequate psychoeducation: The couple was warned about recurrence of postpartum illness. Mr. Yates explained that the couple would talk it over when Mrs. Yates felt better and they decided to have more children. Mr. Yates felt that they should have as many children as they could. Mrs. Yates was hesitant to take medication during her pregnancies. This thinking has drastically changed over the years. We now understand that some women must be medicated during pregnancy and that the risk of medication may be less than the risk of illness. Early pharmacological intervention during pregnancy would likely have prevented a recurrence of psychosis.
Poor medical management of puerperal psychosis: For unclear reasons, the treating psychiatrist discontinued Andrea Yates from antipsychotic medication. In general, she failed to receive an acceptable standard of medical care.
Stigma and lack of public education: Her friend wrote in a journal and warned Mr. Yates that Andrea smelled like she had not bathed in days and paced “like a caged animal.” Unfortunately, the public is not well-educated about recognizing mental illness and getting proper help.
The Future
The question we must ask ourselves is: why does stigma continue to exist with an illness that has the same biological underpinnings as any other life-threatening illness for which emergency services would have been called?
We, as a society failed Andrea Yates. We share equal responsibility for the tragedy. Friends, neighbors and family watched as Mrs. Yates continued to decompensate. The medical community failed to provide appropriate protection, social work assistance and child services to a severely psychotic mother of five children. When the legal community and her state failed to appreciate the severity of her illness, they eliminated her last opportunity for appropriate treatment. It was only after the recent trial, in which she was found Not Guilty by Reason of Mental Illness, that she was mandated to a psychiatric institution where she has been treated appropriately.
Although stories like those of Andrea Yates are rare, they continue to occur. Many women are serving life sentences. As a major public health problem, postpartum psychiatric illness is predictable, identifiable, treatable and therefore, most importantly, preventable.
Those of us who pursue the goal of prevention will be obliged to override any anger or revulsion we may feel with the compassion and courage to seek a more in-depth understanding of infanticide. We, as a society, could do a far better job of preventing these tragedies.
What is required of us is to not look away, but to communicate with and learn from these mothers. The great promise of understanding them better will play out in incalculable saved lives.
Early Identification:
Women come to us in obstetricians’ offices, prenatal clinics and well baby centers. We meet their families and children. They complete questionnaires and attend interviews by physicians, nurses and social workers. How do we miss the warning signs of potential tragedy in one of the most available populations in health care?
Recognizing antepartum screening as the best intervention strategy to identify women at risk, the obstetrician’s or midwife’s office or prenatal clinic are the optimum environments to use simple screening tools to identify women at risk in time for intervention.
CBS Cares’ public service announcements can be invaluable because education is the best tool for prevention and early identification of mothers and children at risk.
For more information on postpartum depression, CBS Cares recommends Postpartum Support International, at www.postpartum.net or 1-800-944-4PPD (1-800-944-4773).