Dealing with postnatal depression
Postnatal depression, like split personality and nervous breakdown, is a catch-all lay term that obscures diagnosis more than it clarifies it.
Mother holding baby Photo: REUTERS/Erik de Castro
For a very small number of women around the globe, the perinatal period can be a
period of tragedy rather than joy. That tragedy may, in the postpartum period,
be due to the death of a newborn or to a newborn’s physical injury or
Tragedy also encompasses major mental illness, technically
termed postpartum psychosis. A mercifully small number of those with this
condition harm their babies, and even in a very few cases kill them. These are
not cases of postnatal depression in the sense in which the term is generally
used. That is reserved for much milder cases. Nor do drug addicts or sociopaths
swell the statistics of maternal filicide. They are in the absolute
It is an unfortunate fact that the distinction between
relatively uncomplicated postpartum depressions and the much rarer, potentially
lethal psychotic forms can be blurred. This is because some women who suffer
from postnatal depression can experience obsessive fear that they could harm
their baby, and actively resist those thoughts. They are not among those that
typically act them out. Their experience is quite distinct from that of
psychotic mothers, whose thoughts of harming their child are mostly not
accompanied by resistance, and tragically, in a few cases, may be acted
The source of the thoughts in such psychotic cases is often
hallucinatory. “Command hallucinations” telling a mother to kill her child, and
the homicidal delusions consequent upon them, however, readily distinguish these
cases from those of postpartum depression – in everyday parlance, postnatal
depression. Hallucination is seeing and hearing things that are not really
there; delusion is believing things that are obviously untrue and
This is a very important distinction to make. Misdiagnosis as
postnatal and perinatal depression in cases of postnatal psychosis, and even
more so misdiagnosing harm to a baby as simply due to postnatal depression, can
only discourage mothers from acknowledging that they are suffering from
postnatal depression, and that they might benefit from professional psychiatric
This possible tragic consequences of this condition have again just
arisen locally with the murder by a mother of her three children.
diagnosis is most likely postpartum psychosis, but a non-psychiatric
professional has gone on public record with a diagnosis of postnatal depression.
Infanticide is definitely not one of the prominent symptoms of non-psychotic
The UK government Internet publication NHS Choices,
which cannot be bettered, differentiates postnatal depression from postnatal
psychosis. Women suffering postnatal depression usually describe sadness and low
mood, anxiety, worrying and agitation, loss of interest, self-neglect, lack of
energy and fatigue. Their sleep and appetite can be impaired (increased or
decreased). Concentration and decision making may be poor. Thoughts that their
baby is abnormal are not uncommon. Confidence, especially when managing the
baby, can be impaired. Often there are difficulties in bonding with their
Not surprisingly there are feelings of guilt. In more severe cases,
there may even be thoughts of self harm, or even suicide. Most mothers with
postpartum depression do not act on these, thoughts, however, nor do they kill
Postnatal psychosis is far rarer and much more
serious. In fact it is a psychiatric emergency, and both mother and baby
must be protected. The mother typically suffers from hallucinations and
delusions. Mood may be impaired – elevated, depressed or simply dysphoric, but
this is generally over-shadowed by the psychosis.
Treatment is always
conducted by psychiatrists in a hospital setting. By way of contrast, ambulatory
treatment is the rule in postpartum depression. With effective medical
management, neither postpartum psychosis nor postpartum depression should have
an unhappy outcome.
Israeli cases cause media outcry, but have yet to
elicit a sustained, professional response from those that either treat or
govern. Statistics are thin on the ground.
One therefore has to look to
the US, which informs Israeli practice anyway, for more than just media
A recent study by the US Department of Justice indicated that
about one in six cases of filicide (the killing of a son or daughter) is of an
infant by the mother (most of the remainder are by fathers of children over the
age of eight years). Not infrequently mothers then try to take their own lives,
and of course some succeed.
Even though delusions and hallucinations, the
sine qua non of postpartum psychosis, are virtually the sine qua non of maternal
filicide, courts and juries struggle to accept the insanity defense. This
particular homicidal act is simply too repugnant to most members of modern
Western society, lay and professional alike.
What is the answer?
Prevention, prevention, prevention.
In a way, filicide is as much a
symptom of the moral health of a nation as that of the mental health of the
individuals that make it up. To the extent that societies provide adequate
support and services for families, and for burdened mothers, filicide will be
The better informed and the more caring a society, the less
likely tragedies like these will occur. Murder of babies by mentally ill mothers
can be prevented.
In Israel, psychiatric services for mothers (and their
babies) are notable for their absence. Most services are restricted to the
center of the country, leaving the north and the south relatively depleted. And
those psychiatric services that are on offer center on mental asylums and their
community outreach clinics. They service a population that rarely includes such
mothers at risk.
The kind of family and community psychiatric services
required to make a significant dent in the statistics for maternal filicide
simply don’t exist locally.
Non-psychiatric professionals, most notably
general medical practitioners and social workers, don’t have the professional
training, knowledge or skills to differentiate cases at risk. The most effective
advocacy for improvement of suitable psychiatric services will only come from
within the psychiatric profession itself.
We have been warned.
writer was trained in medicine and psychiatry in London and ran the psychiatric
residency training program at Hadassah Hospital. He is completing a book
on Suicide in Jewish History and the Holocaust for the Edwin Mellen Press.