The Lindsey Clancy Case: What We Still Get Wrong About Postpartum Psychosis

The Lindsey Clancy case is almost impossible to talk about without having an emotional reaction. Three young children died. Their mother is accused of killing them. Their father lost his entire family in a matter of minutes. There is no version of this story that is not devastating.

As a psychiatric provider, there is another part of this case that I keep coming back to: how poorly postpartum psychosis is understood.

I have watched people point to details of Lindsey Clancy's behavior as evidence that she could not have been psychotic. She reportedly planned. She was able to have conversations. She had periods when she appeared organized and coherent. There were moments when she seemed like herself.

The assumption is understandable. If someone can plan something, doesn't that mean she knows what she is doing?

Not necessarily.

That is one of the most important things to understand about postpartum psychosis.

Postpartum psychosis is not postpartum depression

Despite the way these terms are sometimes used in the media, postpartum depression and postpartum psychosis are very different illnesses.

Postpartum depression can be severe and absolutely requires appropriate treatment. Postpartum psychosis, however, involves a significant disruption in a person's perception of reality and is a psychiatric emergency.

A woman experiencing postpartum psychosis may develop delusions, paranoia, hallucinations, severe confusion, disorganized thinking, unusual religious or grandiose beliefs, or symptoms of mania. Sleep can deteriorate dramatically. Perhaps most importantly, insight can disappear. She may not recognize that she is sick.

Postpartum psychosis also does not necessarily look like the version of psychosis most people imagine.

Symptoms can fluctuate significantly. Someone may appear confused, manic, or delusional at one point and later speak coherently, interact normally with her children, or convince the people around her that she is doing better.

That temporary appearance of being "back to normal" does not necessarily mean the illness has resolved.

Psychosis can look surprisingly organized

When most people hear the word "psychosis," they picture someone visibly disconnected from reality: talking to people who aren't there, behaving bizarrely, or unable to carry on a normal conversation.

Sometimes psychosis looks exactly like that. Sometimes it doesn't.

A person can be surprisingly organized while operating from a belief that is profoundly disconnected from reality.

Imagine someone genuinely believes that her children are facing a terrible fate and that she alone has been given a way to save them. She may take deliberate steps based on that belief. She may wait for a particular moment. She may search for information. She may make a plan.

The fact that the behavior involves planning does not make the underlying belief rational.

Planning and psychosis are not mutually exclusive.

I think this is particularly important in the discussion surrounding Lindsey Clancy because evidence of planning is often treated publicly as proof that someone could not have been psychotic.

Psychiatrically, it simply does not work that way.

That does not answer the legal question of criminal responsibility. The legal standard is different from a psychiatric diagnosis, and ultimately that determination belongs to the court after reviewing evidence and expert evaluations.

The presence of purposeful or organized behavior, by itself, does not rule out psychosis.

The connection with bipolar disorder

Postpartum psychosis is rare, but when it occurs, it is extremely serious. It also has a strong relationship with bipolar-spectrum illness.

For some women, pregnancy and childbirth may surround the first recognizable manic or psychotic episode of their lives. They may have never previously been diagnosed with bipolar disorder.

This is why psychiatric and family history matter. A personal or family history of bipolar disorder, psychosis, psychiatric hospitalization, or postpartum psychosis can be important information when evaluating a woman during pregnancy or after delivery.

Sleep is another important clue.

There is a difference between insomnia and a decreased need for sleep.

A mother with anxiety or depression may desperately want to sleep but cannot. She is exhausted and wishes she could sleep.

Someone becoming manic may sleep only a few hours and feel that she does not need more. She may be unusually energized, driven, productive, agitated, grandiose, or simply very unlike herself.

In the postpartum period, that change deserves attention.

Postpartum psychosis is not postpartum OCD

This may be the most important distinction for new mothers to understand.

Intrusive thoughts involving a baby can occur with postpartum anxiety and OCD, and they can be terrifying.

A mother might suddenly have an image of dropping her baby down the stairs. She might think, "What if I lose control and hurt my baby?" The thought may frighten her so much that she avoids being alone with the baby, hides knives, repeatedly checks that the baby is safe, or seeks constant reassurance.

The fact that the thought horrifies her matters.

These thoughts are typically ego-dystonic, meaning they are unwanted and inconsistent with what the person actually believes or wants. She recognizes the thought as disturbing. She does not want to act on it.

Psychosis is fundamentally different.

A mother experiencing postpartum psychosis may genuinely believe something that is not true. She might believe her baby is possessed, that someone is coming to harm her children, that God has given her a mission, or that death is somehow necessary to protect them.

Within that altered reality, something horrifying to everyone around her may seem logical or even necessary to her.

And unlike the mother experiencing OCD, she may have little or no awareness that these beliefs are a symptom of illness.

That loss of insight is part of what makes postpartum psychosis so dangerous.

Why I worry about how we talk about these cases

When postpartum OCD, postpartum depression, and postpartum psychosis all get lumped together, there is another unintended consequence.

Women become afraid to tell anyone what they are thinking.

A new mother experiencing intrusive thoughts may hear a case like this and think, "If I tell someone that I had an image of hurting my baby, they're going to think I'm dangerous. They're going to take my baby away."

So she stays quiet.

That is exactly what we do not want.

Intrusive thoughts are far more common than postpartum psychosis. Having a frightening, unwanted thought about harming your baby does not mean that you want to harm your baby.

We need mothers to feel safe telling their OB, therapist, psychiatrist, primary care provider, or even their child's pediatrician what they are experiencing.

At the same time, actual signs of psychosis need to be treated with urgency. Delusions, hallucinations, severe confusion, dramatically decreased need for sleep, mania, bizarre or fixed beliefs, major behavioral changes, or loss of insight require immediate psychiatric evaluation.

Postpartum psychosis is a psychiatric emergency and often requires hospitalization. Treatment commonly involves antipsychotic medication, and lithium has particularly strong evidence in the treatment and prevention of postpartum psychosis. Protecting sleep is also an important part of treatment and recovery.

This is not something a family should be expected to manage on its own.

Where I land on the Lindsey Clancy case

I want to be careful here. I did not evaluate Lindsey Clancy. I do not have access to her complete medical record, and psychiatric diagnosis and legal responsibility are two separate questions.

At the same time, I don’t think we should ignore what this case is teaching us about severe postpartum mental illness.

The details that people often point to as evidence that she "knew what she was doing" do not, on their own, exclude psychosis. A person can plan while psychotic. She can have periods of apparent clarity while severely ill. She can answer questions coherently. She can love her children deeply. She can also be operating within a reality that has become profoundly distorted.

Personally, based on what has been publicly reported about the psychiatric circumstances surrounding this case, I have serious concerns about treating it as though it were an ordinary criminal act divorced from severe mental illness. I am deeply uncomfortable with the prosecution of a woman if her actions occurred in the context of postpartum psychosis.

That position does not require minimizing what happened.

Cora, Dawson, and Callan Clancy died. Their lives matter. Their father's loss is almost impossible to comprehend. Understanding the psychiatric illness potentially involved does not make what happened less horrific.

Compassion for the children and recognition of severe mental illness are not mutually exclusive.

Neither are planning and psychosis.

Perhaps that is the part of this case I most want people to understand.

Postpartum psychosis does not always look like someone who is obviously "crazy." It can fluctuate. It can look organized. It can temporarily hide behind moments of clarity. And by the time everyone agrees that something was terribly wrong, it may already be too late.

The goal should be to recognize it sooner.