Dealing with postnatal depression

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 illness.

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 minority.

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 upon.

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 illogical.

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 help.

This possible tragic consequences of this condition have again just arisen locally with the murder by a mother of her three children.

The 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 postnatal depression.

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 baby.

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 their babies.

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 blurb.

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 mitigated.

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.

The 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.