Postpartum Psychosis: An Ethical Debate, by Maria Girardi

Pregnancy and the postpartum period are usually an exciting and joyful experience for women. This does not mean that this period is perfect and problem free. Some women suffer from the “baby blues”, postpartum depression and even more severe postpartum psychosis. Unfortunately, there have been cases where women with severe postpartum psychosis have resulted in killing their own children. An ethical issue arises when these women go on trial because the legal system has to determine if the courts will push for the death penalty.  The use of the death penalty is unethical if the person is determined insane because the woman suffers from postpartum psychosis.

Distinguishing the difference between the “baby blues”, postpartum depression (PPD), and postpartum psychosis (PP) is crucial to understand when determining the correct punishment for women.  The “baby blues” also known as “maternal blues” is the most common type out of the three. According to the Medical Doctors Clay and Seehusen (2004), “Many women fifty to eight-five percent experience the “baby blues,” characterized by mild depressive symptoms, anxiety, irritability, mood swings, tearfulness, increased sensitivity, and fatigue”  (Clay, Seehusen, 2004, p.158). The peak for the “baby blues” is usually four to five days postpartum and typically resolves within ten days (Clay, Seehusen, 2004). Although the symptoms of the “baby blues” are stressful, they usually do not affect the woman’s ability to care for her children. Even though postpartum depression is less common than the “baby blues” PPD is more common than physicians realize.

Postpartum depression is described as depression after giving birth. According to Connell, PPD occurs in ten to twenty percent of women and may persist for one year (Connell, 2001). Women with a history of PPD have a higher risk for developing the depression again than a woman who has not previously had PPD.  More known risk factors for PPD include “prior experiences with major depression, other mental illnesses, PPD, or antenatal depression; complications or dissatisfaction with labor and delivery; and other concurrent significant life stressors such as divorce, loss, illness, or major transitions” (Clay, Seehusen, 2004). Moreover, “Postpartum depression is categorized as a type of reactive depression and depression involves feelings of hopelessness, inadequacy, anxiety and moodiness” (Connell, 2001, P.145-146). Mother’s may have feelings as failure as a mother and have difficulties dealing with daily task. Mother’s may have a lack a confidence in their parenting and believe that they cannot accomplish anything right; therefore, making daily life tasks difficult to complete.

Detecting PPD in women is complicated by several factors. Physicians may have difficulties diagnosing PPD because the symptoms are extremely similar to depression. “The Diagnostic and statistical Manual of Mental Disorders, Fourth edition (DSM-IV), requires that symptoms of major depression with postpartum onset begin within four weeks of childbirth; however, reports in the literature suggest that episodes of depression are common up to two years after delivery and that these later episodes should also be considered postpartum depression” (Ross, Murray, Steiner, 2005, p. 247). Improving the diagnosing will help mothers suffering from PPD get the correct treatment and improve the quality of life for the mother and her family. In addition, mothers need a time to adjust after delivering a baby, especially first-time mothers because they might not know that what they are experiencing is normal and if the mother can recognize that her mood is abnormal, she may feel ashamed to admit her feelings (Ross, Murray, Steiner, 2005). The challenges associated with the detection of PPD and PP can have devastating consequences because early detection and treatment is crucial.

Different from PPD, psychosis is a fundamental derangement of the mind characterized by defective or lost of contact with reality especially evidenced by delusions, hallucinations, and disorganized speech and behavior. According to Connell, “Postpartum psychosis was thought to be the same as a psychosis that a man or woman who had not recently given birth. However, the fact is that women suffering from postpartum psychosis have been shown to be more delusional, disoriented, and agitated with greater frequency than men or women suffering from psychosis unrelated to childbirth” (Connell, 2002, p. 146). Postpartum psychosis (PP) is different from PPD because PP can lead to infanticide or to suicide (Connell, 2002).  The baseline risk for PP is one in five hundred; however, the risk rises to one in seven for women with even one past episode of PP (Sit, Rothschild, & Wisner, 2006).  According to Hunt (2006), “Onset is an abrupt and most commonly occurs in the firsts four weeks after birth. Symptoms include thought and perceptual disturbances such as delusions, auditory or visual hallucinations and disorganized behavior” (Hunt, 2006, p. 206). Several studies have shown that a majority woman who develop psychosis after childbirth have bipolar disorder (Sharma & Mazmanian, 2003). PP can lead to devastating consequences in which the safety and well-being of the affected mother and her offspring are jeopardized. Therefore, careful and repeated assessment of the mothers’ symptoms, safety, and functional capacity is imperative (Sit, Rothschild, & Wisner, 2006).

In addition, PP must be distinguished from postpartum obsessive-compulsive disorder (OCD). OC symptoms and OCD are characterized by intrusive thoughts and compulsive, irresistible behaviors (Sit, Rothschild, Wisner, 2006). Moreover, “OC or OCD is differentiated from PP by the preservation of rational judgment and reality testing; patients typically do not act on their aggressive thoughts. Rather, they avoid object or places that provoke anxiety and suffer discomfort from their unwanted cognitions” (Sit, Rothschild, Wisner, 2006, p. 359).

According to Abrams and Curran, 2007, “Many researchers, particularly those in medical fields, suggest that hormonal changes during pregnancy and the postpartum period, along with predisposing genetic factors, contribute to PPD. These hormonal shifts include fluctuations in levels of estrogen, progesterone, luteinizing hormone, follicle-stimulating hormone, and cortisol” (Abrams and Curran, 2007, p. 291). In addition, research suggests that postpartum psychosis results from sudden postpartum withdrawal of estrogen on the dopaminergic system and PP is associated with increased sensitivity in the dopamine receptors (Sharma & Mazmanian, 2003). According to Sharma and Mazmanian, “Melatonin may act as an endogenouse ‘antipsychotic hormone’ by blocking the presynaptic dopamine releases in the limbic system. A marked reduction in plasma melatonin levels may lead to acute disinhibition of limbic dopaminergic activity in the postpartum period resulting in increased dopamine released and the stimulation of supersensitive dopamine receptors” (Sharma & Mazmanian, 2003, p. 99). Therefore, the use of bright light and administrating bright light may be used as a possible treatment.

According to researchers, “Animal studies suggest that structural changes occur in the maternal brain during the early postpartum period in regions such as the hypothalamus, amygdala, parietal lobe, and prefrontal cortex and such changes are related to the expression of maternal behaviors (Leckman, Mayes, Feldman, Wang & Swain, 2010, p. 695). A study was conducted on humans in which researchers examined gray matter of women’s brain at two different points in time; two to four weeks postpartum and three to four months postpartum. “Researchers found increases in gray matter volume of the prefrontal cortex, parietal lobes, and midbrain areas. Increased gray matter volume in the midbrain including the hypothalamus, substantia nigra, and amygdala was associated with maternal positive perception of her baby. These results suggest that in the first months of motherhood in humans are accompanied by structural changes in brain regions implicated in maternal motivation and behaviors” (Leckman, Mayes, Feldman, Wang & Swain, 2010, p. 695).

Additionally, changes in sleep physiology and sleep deprivation have been hypothesized as having a role in postpartum psychotic disorders (Ross, Murray, & Steiner, 2005). According to research, “Sleep results from alterations in the balance of major neurotransmitter systems in the brain. Serotonin, norepinephrine, histamine, dopamine, melatonin, aminobutyric acid and acetylcholine are all major players in the coordination of sleep and wake behaviors” (Ross, Murray, Steiner, 2005, p. 248). Several of the neurotransmitters systems are involved in the regulation of sleep and are responsible for multiple functions of the brain; therefore, researchers are not surprised that significant interaction could occur between sleep and psychiatric disorders (Ross, Murray, Steiner, 2005). Sleep disruption is common during the last stages of pregnancy and the early postpartum period. For instance, “A study found that the postpartum period was associated with recovery of stage 4 sleep and a reduction of REM sleep” (Sharma & Mazmanian, 2003).

Moreover, studies have described insomnia as one of the most common symptoms of PP with a prevalence of forty-two percent to one hundred percent of patients with postpartum psychosis (Sharma & Mazmanian, 2003). Research determined that education and prevention are essential to helping mothers. Women can take steps such as minimizing sleep deprivation during the hospital stay, by doing only demand feedings instead of routine, an increased duration of the postpartum hospital and limited visiting hours (Ross, Murray, Steiner, 2005). In addition, women who breast-feed are encouraged to pump milk during the day for nighttime feeding or use formula at night.

Postpartum depression and postpartum psychosis are two very serious mental disorders that can affect numerous individuals and families. Many individuals learned the devastating consequences of the mental disorders through the Andrea Yates story. The tragedy brought media attention to the seriousness of postpartum depression and postpartum psychosis. Andrea Yates had a history or two suicide attempts and been hospitalized both times with the diagnosis of PPD and PP.  “Up until the moment Andrea Yates murdered her five children, she could have been any mother in America: devoted to her family, often at wit’s end, setting aside her own wants and needs for the sake of her loves ones” (Hollandsworth, 2001, p115). She and her husband were devout Christians. Andrea was a stay at home mother and Russell Yates her husband worked at the Johnson space center as a NASA engineer. “According to news media accounts he was a straight- laced Christian traditionalist, who did not want his wife working outside the home, did not want her using baby-sitters because they might teach the children too many wordy attitudes” (Hollandworth, 2001,  p116).

One the morning of Wednesday June 20, between 9am and 10:30 am, Andrea Yates drowned her five children in the family bathtub. Yates called herself a bad mother and that her children were not developing normally; therefore, she decided to send them to God (Hollandworth, 2001). Yates called the police on herself and was immediately arrested for capital murder.  “After a jury trial in 2001, she was found guilty by reason of insanity, not to the death penalty, which prosecutors had sought, but to life in prison. Then on July 26, 2006, she was acquitted by reason of insanity and committed to a state mental hospital” (McLellan, 2006, p. 1952). An ethical issue arises when determining the correct punishment for women who kill their children.

Each state has their own insanity defense statue. About fifty percent of states use a test created by the American Law Institute that states, “A person would not be responsible for a criminal conduct if at the time of conduct as a result of mental disease or defect he  lacks substantial capacity either to appreciate the criminality (wrongfulness) of his conduct or to conform his conduct to the requirements of law” (Meier, 2002, p. 297). Besides the issue about the discrepancies in the insanity defense, the judicial system has to decide if it is ethical to treat (sometimes forcefully) an individual with medication so that they are ‘sane’ during the trial (Meier, 2002).

Postpartum depression and postpartum psychosis are both serious mental disorders that can have devastating consequences on the mother and her family if not treated correctly. Unfortunately, as many as fifty percent of woman with PPD may be undiagnosed; therefore receiving no treatment. If problems persist, the mother’s depression may turn into flow blown psychosis, which may lead to infanticide or suicide. It is horrible to hear causes of women who kill their own children. Most individuals who believe in capital punishment would want the woman to be put to death for killing her own children, but the judicial system has to decide if the woman was insane at the time of the murder. If the woman is found insane because of postpartum psychosis, it is unethical to use the death penalty on her because she was not in her right state of mind. A more appropriate option would be to have the woman treated in a mental hospital for her disorder.

References

Abrams, L., & Curran, L. (2007). Not Just a Middle-Class Affliction: Crafting a Social Work Research Agenda on Postpartum Depression. Health & Social Work, 32(4), 289-296.  Retrieved from Academic Search Premier database.

 Clay, E., & Seehusen, D. (2004). A Review of Postpartum Depression for the Primary Care Physician. Southern Medical Journal, 97(2), 157-161. Retrieved from Academic Search Premier database.

Connell, M. (2002). THE POSTPARTUM PSYCHOSIS DEFENSE AND FEMINISM: MORE OR LESS JUSTICE FOR WOMEN?. Case Western Reserve Law Review, 53(1), 143. Retrieved from MasterFILE Premier database.

Hollandsworth, S. (2001). her dark places. Texas Monthly, 29(8), 114. Retrieved from MasterFILE Premier database.

Kim, P., Leckman, J., Mayes, L., Feldman, R., Wang, X., & Swain, J. (2010). The plasticity of human maternal brain: Longitudinal changes in brain anatomy during the early postpartum period. Behavioral Neuroscience, 124(5), 695-700. doi:10.1037/a0020884.

McLellan, F. (2006). Mental health and justice: the case of Andrea Yates. Lancet, 368(9551), 1951-1954. doi:10.1016/S0140-6736(06)69789-4.

Meier, E. (2002). Andrea Yates: Where Did We Go Wrong?. Pediatric Nursing, 28(3), 296.           Retrieved from Academic Search Premier database.

Ross, L., Murray, B., & Steiner, M. (2005). Sleep and perinatal mood disorders: a critical review.  Journal of Psychiatry & Neuroscience, 30(4), 247. Retrieved from Academic Search Premier database.

Sharma, V., & Mazmanian, D. (2003). Sleep loss and postpartum psychosis. Bipolar Disorders, 5(2), 98-105. doi:10.1034/j.1399-5618.2003.00015.x.

Sit, D., Rothschild, A., & Wisner, K. (2006). A Review of Postpartum Psychosis. Journal of Women's Health (15409996), 15(4), 352-368. doi:10.1089/jwh.2006.15.352.