U.S.PSYCH: Postpartum Depression and Psychosis Easily Missed

NEW ORLEANS, Nov. 21 -- The example of Andrea Yates, who drowned her five children in a bathtub five years ago, illustrates the difficulty of identifying postpartum psychosis, said a psychiatrist who testified in her defense.

Yates had been under psychiatric care for postpartum depression after the birth of her fourth child in 1999, and Yates had seen a psychiatrist just two days before the drownings, said Phillip J. Resnick, M.D., of Case Western Reserve University in Cleveland, at the U.S. Psychiatric & Mental Health Congress meeting here.

Dr. Resnick was an expert witness in the Yates trial that resulted in the verdict of not guilty by reason of insanity.

While up to 80% of new mothers will get the "baby blues," only 10% to 15% are diagnosed with postpartum depression. And less than 1% will experience psychosis with that depression, according to the National Institutes of Health.

But postpartum depression may be more prevalent than thought, because women are reluctant to reveal the symptoms, Dr. Resnick said. Fearing of falling short of society's ideal of motherhood, women may hold back from telling their husbands. And many fear that if they tell a doctor or social worker about their depression, their baby might be taken away, he said.

About 40% of mothers with postpartum depression have thoughts about killing their child, Dr. Resnick said. And for depressed mothers of "colicky" babies-babies not soothed even when fed, changed, and held-that figure climbs to 70%, he said.

Of the mothers whose depression develops into psychosis, as it did with Yates, about 4% will harm their children if the psychosis is not treated, Dr. Resnick said.

But Dr. Resnick offered some hope. A recent study he conducted of parents who had killed their children found that 75% had depressive symptoms beforehand that could have been detected, he said.

If, during a clinical visit, a depressed mother is talking about suicide, it is important for a clinician to ask what her plans would be for her children if she took her own life. The woman may say that her husband or other family members will take care of the children. But she may say something along the lines of "I will take them with me," Dr. Resnick said.

The Yates case illustrates the concept of "rationality within irrationality," Dr. Resnick added. While it may be supposed that someone suffering from a psychotic delusion is incapable of acting rationally, the person may in fact be able to act quite rationally even though their premise -- the cause for action -- is delusional, he said.

Yates was under the delusional belief that her children were not "righteous" and would end up in hell if she didn't do something. "Once she had that delusional belief, she acted rationally in killing her children before the age of accountability," he said. In Yates' mind, she was ensuring her children would go to heaven.

"This means an insane person can premeditate and plan a crime," he said.

Does having strong religious faith predispose a person to psychosis? "No," Dr. Resnick said, "but in this case, religion was the trellis along which the delusion grew."