In June 2001, Andrea Yates drowned her 5 children ages 6 months to 7 years in the bathtub of their home. She had delusions that her house was bugged and television cameras were monitoring her mothering skills. She came to believe that “the one and only Satan” was within her, and that her children would burn in hell if she did not save their souls while they were still innocent.
Her conviction of capital murder in her first trial was overturned on appeal. She was found not guilty by reason of insanity at her retrial in 2006 and committed to a Texas state mental hospital.1
Postpartum psychosis (PPP) presents dramatically days to weeks after delivery, with wide-ranging symptoms that can include dysphoric mania and delirium. Because untreated PPP has an estimated 4% risk of infanticide (murder of the infant in the first year of life),2 and a 5% risk of suicide,3 psychiatric hospitalization usually is required to protect the mother and her baby.
The diagnosis may be missed, however, because postpartum psychotic symptoms wax and wane and suspiciousness or poor insight cause some women—such as Andrea Yates—to hide their delusional thinking from their families. This article discusses the risk factors, prevention, and treatment of PPP, including a review of:
- infanticide and suicide risks in the postpartum period
- increased susceptibility to PPP in women with bipolar disorder and other psychiatric disorders
- hospitalization for support and safety of the mother and her infant.
Risks of infanticide and suicide
A number of motives exist for infanticide (Table 1).4 Psychiatric literature shows that mothers who kill their children often have experienced psychosis, suicidality, depression, and considerable life stress.5 Common factors include alcohol use, limited social support, and a personal history of abuse. Studies on infanticide found a significant increase in common psychiatric disorders and financial stress among the mothers. Neonaticide (murder of the infant in the first day of life) generally is not related to PPP because PPP usually does not begin until after the day of delivery.6
Among women who develop psychiatric illness, homicidal ideation is more frequent in those with a perinatal onset of psychopathology.7 Infanticidal ideas and behavior are associated with psychotic ideas about the infant.8 Suicide is the cause of up to 20% of postpartum deaths.9
Table 1
Motives for infanticide: Mental illness or something else?
| Motives | Examples |
|---|---|
| Likely related to postpartum psychosis or depression | |
| Altruistic | A depressed or psychotic mother may believe she is sending her baby to heaven to prevent suffering on earth |
| A suicidal mother may kill her infant along with herself rather than leave the child alone | |
| Acutely psychotic | A mother kills her baby for no comprehensible reason, such as in response to command hallucinations or the confusion of delirium |
| Rarely related to postpartum psychosis | |
| Fatal maltreatment | ‘Battered child’ syndrome is the most common cause of infanticide; death often occurs after chronic abuse or neglect |
| A minority of perpetrators are psychotic; a mother out of touch with reality may have difficulty providing for her infant’s needs | |
| Not likely related to postpartum psychosis | |
| Unwanted child | Parent does not want child because of inconvenience or out-of-wedlock birth |
| Spouse revenge | Murder of a child to cause emotional suffering for the other parent is the least frequent motive for infanticide |
| Source: Reference 4 | |
The bipolar connection
Many factors can elevate the risk of PPP, including sleep deprivation in susceptible women, the hormonal shifts after birth, and psychiatric comorbidity (Table 2). Nearly three-fourths (>72%) of mothers with PPP have bipolar disorder or schizoaffective disorder, whereas 12% have schizophrenia.10 Some authors consider PPP to be bipolar disorder until proven otherwise. Mothers with a history of bipolar disorder or PPP have a 100-fold increase in rates of psychiatric hospitalization in the postpartum period.11
Presentation. PPP is relatively rare, occurring at a rate of 1 to 3 cases per 1,000 births. Symptoms often have an abrupt onset, within days to weeks of delivery.10 In at least one-half of cases, symptoms begin by the third postpartum day,13 when many mothers have been discharged home and may be solely responsible for their infants.
Symptoms include confusion, bizarre behaviors, hallucinations (including rarer types such as tactile and olfactory), mood lability (ranging from euphoria to depression), decreased need for sleep or insomnia, restlessness, agitation, disorganized thinking, and bizarre delusions of relatively rapid onset.13 One mother might believe God wants her baby to be sacrificed as the second coming of the Messiah, a second may believe she has special powers, and a third that her baby is defective.