WARNING: This article includes descriptions of violence against children and suicide.
Upon stepping onto the subway in New York City after work, Meghan Cliffel sensed that something was seriously amiss as she noticed the glances of her fellow commuters.
While those around her were busy with their phones or listening to music, the mother of two felt as if they were monitoring her. To escape this perceived danger, she switched trains and proceeded to a reunion with old friends.
However, her anxiety did not subside; ultimately, she hurried across the city to reach home, fearing that someone might threaten her family after a friend innocently inquired about who was caring for her daughters, aged two and eight months.
“My mind was weaving together a complex narrative where I believed there was some sort of cult-like operation controlling the city,” she explained. “I felt like I was at the center of it and that they were targeting me and my children.”
In reality, she was experiencing postpartum psychosis, a rare illness that impacts approximately one to two mothers per 1,000 births, which is currently a focal point in the first-degree murder trial of Lindsay Clancy in Massachusetts, where she faces allegations of murdering her three children.
This condition is classified as a psychiatric emergency and demands immediate intervention, according to Nicholas Leyland, president of the Society of Obstetricians and Gynaecologists of Canada (SOGC) based in Ontario. Symptoms can include delusions, hallucinations (both visual and auditory), distorted thoughts, paranoia, mania, depression, insomnia, and confusion.
However, when Cliffel first encountered her delusions on December 4, 2015, she noted that neither she nor her husband had any knowledge of the disorder.
‘Excruciating to witness’
Now, ten years later, she is thriving as a mother of three, a writer, and an advocate for maternal mental health. She described it as “excruciating to witness” the Clancy trial because she can imagine her own situation ending in a similar way had her husband left her alone with their children — and because postpartum psychosis is both temporary and treatable.
Lindsay Clancy waits for the judge to call a prospective jury member into court on July 22 during her murder trial where she is charged in the 2023 killing of her three children. The jury is now deliberating a decision in the case. (Greg Derr/The Patriot Ledger/The Associated Press)
One of the significant hurdles, as both she and Clancy discovered, is obtaining an accurate diagnosis.
Jurors are currently weighing whether the 36-year-old former labor and delivery nurse should be held accountable for the deaths of her children, Cora, 5; Dawson, 3; and eight-month-old Callan in 2023 while her husband was out running an errand.
She is alleged to have strangled the children with exercise bands in the basement of her home near Boston before jumping from a second-story window after inflicting a neck wound in an attempt to end her own life. Currently, she is paralyzed and relies on a wheelchair.
Her defense team contends that Clancy should not be deemed criminally responsible, arguing that her medical condition led to a skewed perception of reality.
Her attorneys stated that Clancy made every effort to seek help for her worsening mental health — from family members and multiple healthcare providers who collectively prescribed her 13 different medications. She contacted a suicide hotline, visited the emergency room, and voluntarily admitted herself to a psychiatric facility. She had been denied a place in an outpatient postpartum mental health program.
Supporters of Clancy and women’s health advocates assert that these efforts highlight the systemic failures within the healthcare system for women and, by extension, their children.
Absent from the DSM-5
While in custody, Clancy received her diagnosis: bipolar disorder and postpartum psychosis.
“It feels somewhat like a different version of my life,” Cliffel remarked. “And it is also excruciating because I know we could do so much better.”
Now an advocate for postpartum mental health residing in Cleveland, Ohio, Cliffel emphasized the necessity of revising the DSM-5 — the manual of psychiatric and mood disorders utilized throughout North America — to recognize postpartum psychosis as a distinct condition rather than a subset of psychosis.
Such a change would enhance awareness among doctors, psychologists, and other maternal health professionals, she argued, and could potentially boost research funding and interest in the condition.
It could also assist others in receiving an early diagnosis.
Cliffel spent 12 days at Bellevue Psychiatric Hospital in New York City; her husband called emergency services on December 5, 2015, when she began hitting him in an effort to reach their children and threatened to leap from the roof.
“I woke up in a dark twin bed and believed I had been captured,” she recalled. “I tried to escape multiple times, thinking maybe my baby girls were still alive.”
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What is postpartum psychosis, the illness at the centre of Lindsay Clancy’s murder trial?
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Postpartum depression or anxiety reported by nearly a quarter of moms: StatsCan
Her condition improved with medication. After her release, she attended outpatient care for six weeks but still lacked a diagnosis.
Without clarity regarding such a “life-altering experience,” Cliffel said she struggled to discern whether her thoughts were genuine.
Consequently, she requested to see a psychiatrist who was also a mother.
“That led me to a professional who understood reproductive psychiatry,” she stated. “It took around two months after my experience for someone to finally identify it.”
Misdiagnoses
After nearly 40 years of instructing healthcare professionals about maternal mental health, Karen Kleiman expressed her continued surprise at how many obstetricians opt to send patients to the emergency room for psychiatric evaluation instead of conducting an assessment themselves.
Karen Kleiman, founder of The Postpartum Stress Center in Pennsylvania, emphasizes the importance of asking the right questions to accurately assess a postpartum mother’s symptoms. (Submitted by Karen Kleiman)
She attributes some overlooked instances or misdiagnoses of postpartum psychosis to the increasingly commercial nature of medicine.
“In the medical field, they have what? Three, four, seven minutes … for a rapid assessment,” said Kleiman, who is the 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 goes beyond their scope of practice. But how long does it actually take to ask one or two meaningful questions?”
These inquiries can determine whether the patient is experiencing mania or if their thoughts are taking on a more psychotic nature — rather than merely concerns about how to safely hold a baby.
“We cannot expect a severely ill woman to articulate how unwell she feels,” Kleiman, a licensed social worker, stated. “If psychotic symptoms are present, it is our responsibility to discover that, to pose the right questions, and to ensure she receives the assistance necessary.”
Risk assessment
This is why Elise Gwyn also performs a risk assessment on new clients, whether it is before or after childbirth. The psychotherapist from Ottawa specializes in perinatal mental health, which spans from pregnancy to one year postpartum, and encourages partners to participate in sessions to provide valuable insights.
Elise Gwyn, a psychotherapist based in Ottawa who works with perinatal women, believes that a partner’s input can be crucial for a healthcare provider in the postpartum phase. (Submitted by Elise Gwyn)
Risk factors for postpartum psychosis include a diagnosis or family history of bipolar disorder, while sensitivity to hormonal changes can indicate that someone might face a mood disorder after giving birth, according to Gwyn.
However, distinguishing the symptoms of postpartum psychosis, such as frightening delusions, from the intrusive thoughts of a healthy new mother or someone dealing with postpartum depression, anxiety, or perinatal obsessive-compulsive disorder can be challenging, Gwyn explained, as the brain’s “alarm system” remains highly alert for potential risks to the baby.
This is why gathering information from partners is vital, as a psychotherapist, family doctor, or obstetrician may only interact with a patient for a limited time. Partners have the benefit of a shared home and history and can highlight concerns that a clinician might overlook.
Cliffel, Gwyn, and Kleiman all stressed that while enhancing education around diagnosis is essential, conveying the message that postpartum psychosis is a temporary and treatable condition is equally important.
With systemic improvements, Cliffel stated — particularly in establishing a standard of care that includes psychiatric evaluation and support — women experiencing postpartum psychosis can not only recover but also thrive as parents and potentially have more children.
Cliffel, pictured with her family during a trip to the Teton mountain range in Wyoming, received excellent mental health support, she stated, prior to embarking on her third pregnancy. (Submitted by Meghan Cliffel)
In November 2019, Cliffel welcomed her third child: a son.
She collaborated with a reproductive psychiatrist and therapist to devise a plan for her pregnancy and the subsequent period. Following the birth, she took lithium preventively for a year, engaged in writing, practiced mindfulness, and avoided returning to work.
“We not only prevented a recurrence but also experienced significantly more joy during the third pregnancy,” Cliffel remarked.
If you or someone you know is facing challenges, here are some resources for assistance:
- Postpartum Support International Canada: Call 1-800-944-4773 or visit the website for online support.
- Canada’s Suicide Crisis Helpline: Call or text 988.
- Provincial and territorial mental health support.
- Kids Help Phone: 1-800-668-6868. Text 686868. Live chat counseling available on the website.
- This guide from the Centre for Addiction and Mental Health provides guidance on discussing suicide with someone you are concerned about.