WARNING: This article contains details about violence against children and suicide.
When Meghan Cliffel stepped onto the subway in New York City after work and caught the eyes of her fellow passengers, she felt as though something had gone gravely wrong.
While those around her scrolled on their phones or listened to music, the mother-of-two believed they were surveilling her. She switched trains, trying to throw off the supposed pursuers and then continued on to a gathering of old friends.
But the unease persisted; eventually, she ran across the city to get home, thinking someone might be about to harm her family when a friend innocuously asked who was watching her daughters, then two and eight months old.
“My brain is knitting things together into this kind of complex reality where I believe there’s some kind of cultish scheme running the city,” she said. “I am in the centre of it in some way and they’re out to get me and my kids.”
In fact, she had postpartum psychosis, a rare condition that affects about one to two mothers per 1,000 births and is currently at the heart of Lindsay Clancy’s defence in her first-degree murder trial in Massachusetts, where she is accused of killing her three children.
The Current24:41Lindsay Clancy trial shines light postpartum mental health
The disorder is considered a psychiatric emergency and requires immediate treatment, said Nicholas Leyland, president of the Society of Obstetricians and Gynaecologists of Canada (SOGC) who is based in Ontario. Symptoms include delusions, visual or auditory hallucinations, distorted thinking, paranoia, mania or depression, insomnia and confusion.
But when Cliffel experienced her first delusions on Dec. 4, 2015, she said neither she nor her husband had heard of the disorder.
‘Excruciating to watch’
Now, a decade later, she is healthy, a mother of three and a writer and maternal mental health advocate. And she finds it “excruciating to watch” the Clancy proceedings, she said, because she can envision her own experience ending similarly had her husband left her alone with the children — and because postpartum psychosis is temporary and treatable.
One of the biggest challenges, however, as she and Clancy found, can be getting a diagnosis.
Jurors are now deliberating whether the 36-year-old former labour and delivery nurse should be held criminally responsible for killing her children, Cora, 5; Dawson, 3; and eight-month-old Callan in 2023 while her then-husband was out on an errand.
She is accused of strangling the children with exercise bands in the basement of her Boston-area home before leaping out a second-storey window after cutting her neck in an attempt to take her own life. She is now paralyzed and uses a wheelchair.
Her defence team has argued that Clancy cannot be held criminally responsible, saying her medical condition created a distorted sense of reality.
Her lawyers described Clancy as doing all she could to get help for her deteriorating mental health — both from family and through numerous health-care providers, who, collectively, prescribed her 13 different medications. She called a suicide hotline, went to the emergency room and checked herself into a psychiatric facility. She had been denied an outpatient spot at a postpartum mental health program.
These attempts, women’s health advocates and Clancy’s supporters say, underscore the systemic failures of the health-care system for women and, by extension, their children.
Missing from the DSM-5
In custody, Clancy got her diagnosis: bipolar disorder and postpartum psychosis.
“It feels a little bit like a different version of my life,” Cliffel said. “And the second reason it feels excruciating is because I know we can do so much better.”
Now a postpartum mental health advocate based in Cleveland, Ohio, Cliffel said it is critical to update the DSM-5 — the handbook of psychiatric and mood disorders used across North America — to include postpartum psychosis as a standalone condition, not a subcategory of psychosis.
Doing so would create more awareness among doctors, psychologists and other maternal health specialists, she said, and likely increase the amount of investment and research into the condition.
And it might help others get an early diagnosis.
Cliffel spent 12 days at Bellevue Psychiatric hospital in New York City; her husband called emergency services the morning of Dec. 5, 2015, when she began punching him to try to get to their children and also threatening to jump from the roof.
“I wake up in a twin bed in the dark and I think I’ve been captured,” she recalled. “I try and escape several times, because I think maybe my baby girls are still alive.”
Her condition improved with medication. After she was discharged, she spent six weeks in outpatient care but still didn’t get a diagnosis.
Without answers about such a “ground-shifting experience,” Cliffel said she had even more difficulty trusting whether her thoughts were real.
So she asked to see a psychiatrist who was also a mother.
“That got me into the chair of somebody who understood reproductive psychiatry,” she said. “So it took, you know, about two months after I experienced it for somebody to label it.”
Misdiagnoses
After nearly four decades of teaching health-care providers about maternal mental health, Karen Kleiman said she is still surprised by how many obstetricians consider sending patients to the emergency room for psychiatric evaluation instead of doing an assessment.
She blames some missed cases or misdiagnoses of postpartum psychosis on the businesslike evolution of medicine.
“The reality is in the medical community, they’ve got what? Three, four, seven minutes … to do a rapid assessment,” said Kleiman, founder of The Postpartum Stress Center in Pennsylvania and author of Good Moms Have Scary Thoughts. “It’s not part of their job description; it’s beyond the scope of their practice. But at the same time, how long does it take to ask one or two good questions?”
Questions can help assess whether the patient is manic, whether the thoughts are manifesting in a more psychotic way — not worries about how to safely hold a baby.
“We cannot expect a woman who’s very, very, very sick to tell us how bad she feels,” said Kleiman, a registered social worker. “If there are psychotic symptoms going on, it’s our burden to find that, to ask the right questions and to get her the help that she needs.”
Risk assessment
It’s why Elise Gwyn also does a risk assessment on new clients, whether it’s before birth or afterward. The Ottawa-area psychotherapist specializes in perinatal mental health, which covers from pregnancy to a year postpartum, and encourages partners to join sessions so they can offer insight.
Risk factors for postpartum psychosis include a diagnosis or family history of bipolar disorder, while sensitivity to hormonal shifts can be a signal someone might experience a mood disorder after delivering, Gwyn said.
But it can be hard to parse the symptoms of postpartum psychosis, such as intrusive thoughts, from the healthy worries of a new mother or someone experiencing postpartum depression, anxiety or perinatal obsessive-compulsive disorder, Gwyn said, because the brain’s “alarm system” is on high alert for risk to the baby.
That’s why collateral information from partners can be critical, Gwyn said, since a psychotherapist, family doctor or obstetrician might only see a patient for a short period of time. Partners have the advantage of a shared home and history and can raise red flags a clinician might miss.
She, Kleiman and Cliffel all emphasized that while more education around diagnosis is important, the message that postpartum psychosis is temporary and treatable is just as critical.
With systemic change, Cliffel said — especially a standard of care that includes psychiatric screening and support — women with postpartum psychosis can not only recover but can be a healthy parent and even go on to have more children.
In November 2019, Cliffel gave birth for the third time: a baby boy.
She worked with a reproductive psychiatrist and therapist to create a plan for pregnancy and beyond. After delivery, she took lithium prophylactically for a year, and she wrote, practised mindfulness and stayed out of the labour force.
“We not only staved off recurrence but we experienced so much more joy the third time around,” Cliffel said.
If you or someone you know is struggling, here’s where to look for help:
