Transcript of Lindsay Clancy Case: The Warning Signs of Postpartum Psychosis | Dr. Blair Steele & Dr. Kenneth Spielvogel

That is so tragic. It irks all of us. We feel it in every cell of our bodies. But if we just judge it, we're not gonna learn anything. It's important that we're curious what could bring someone to do something like this. It's the only way we'll get some information and hopefully be more preventative in the future. If someone has a problem with substance use disorder, please call One Call Placement. That's 888-831-1581. And if we can't help you, we'll make a referral to someone who can. Please, we're out of time. One Call Placement is affiliated with Carrera Treatment Wellness and Spa and One Method Treatment Centers.

Before we start the conversation today, I want to deliver a personal message. Every day, families across America lose someone they love to an overdose. Many of those deaths are preventable when communities have the right education, resources, and support. That's why I've partnered with the CDC Foundation through their COPE, Community Overdose Prevention Efforts, campaign and committed to matching every donation dollar for dollar up to $25,000. I've spent my life helping people recover from addiction, but if we can get to the place of prevention first, this would help save so many more lives. I hope you'll join me in supporting the CDC Foundation's overdose prevention work at CDCfoundation.org/cope. You can also visit the link below in the show notes to donate. Thank you from the bottom of my heart. The Lindsay Clancy trial has ended without a verdict after a deadlocked jury led to a mistrial. Regardless of what happens next in this courtroom, this case has put postpartum psychosis into the national spotlight. What is it? What are the warning signs? And what do families need to know before a situation becomes a crisis? I'm joined by 2 of our experts at Carrera Treatment, psychologist Dr. Blair Steele and Dr. Kenneth Spielvogel, who spent nearly 30 years as an OB-GYN and now works in addiction medicine.

They're here to help us understand what postpartum psychosis really looks like, what they've seen in their clinical work, And what families and loved ones need to know when someone may be in danger. Blair, Kenny, welcome to We're Out of Time. Let's start with the most important basic question. What is postpartum psychosis?

Postpartum psychosis is a severe and sudden mental health condition that can occur. It's, I want to say it's 1 to 2 out of every 1,000. We could fact-check that. births. Um, and it's very serious and it could be very sudden. And it, you know, unfortunately tragedies like the Lindsay Clancy case are just highlighting a lot of gaps in information and gaps in care.

Kenny, you got a comment?

I can add a little more. I think it's best if we're going to look at that to define postpartum depression versus postpartum psychosis. So postpartum depression is relatively common. It's 7 to 10% of all women postpartum. It's defined as starting anytime within that peripartum period, which is before birth and then after birth. Generally, it honestly has a formal definition, the DSM criteria, of up to 4 weeks postpartum, which I think in this case is particularly kind of important when they're going to look at it legally. Postpartum depression is generally, you know, more common in women with a history of postpartum depression, history of other comorbidities such as bipolar or major depression. It is without any kind of psychotic features, which is what pushes us into postpartum psychosis, which is generally auditory hallucination, visual hallucinations, a dissociation without insight into their disease. So those are some really clear distinctions between the two. So, I mean, it's a tragic case.

It's—

I think why it has the public's attention is for a variety of reasons, never mind just the death of 3 children at the hands of their mother. Also in combination with the idea that she attempted to kill herself in the aftermath of it. That's shocking enough as it is, obviously. to draw people in. But on top of that, this woman was a labor and delivery nurse. So she had had a history of postpartum depression in 2 previous pregnancies. In this pregnancy, after delivery, and this occurred, she actually, you know, killed her children 8 months, the youngest child was 8 months old. So she had been in and out of several hospitals She had been on up to, I believe, up to like 50 antipsychotic and antidepressive type medications. She was constantly having relapses. She reported auditory hallucinations and even a, you know, a drive, an intent voice telling her to kill her children.

And this was all prior to killing the children?

Yeah.

And it's all documented.

All—

well, it's interesting. So one of the things that's difficult to point is the day before the crime, she saw her psychiatrist, and in their medical notes it said— again, we know how well doctors document for the most part, which is not very good—

Uh-huh.

But there is a comment of no evidence of psychotic features.

Uh-huh.

Did they talk to the guy?

Yeah, I mean, he was deposed in the course of the trial. I have not, to be full disclosure, I have not watched any of the footage or, you know, much of the, you know, day-to-day coverage of the trial, but this is all through reading.

Yeah, either have I. It did say that she went to doctors for years complaining of these problems, right?

Yeah.

Yeah, I mean, she had severe postpartum depression in 2 pregnancies before.

Mm-hmm.

And elements of postpartum psychosis in this one, so.

Where was the husband?

He—

she sent him out. So this is where it really gets tripped up. She sent him out for food on errands and then did this. So they're saying she premeditated, therefore she couldn't have been psychotic. Which is ridiculous. You can be psychotic and still, you know, have a plan about what you're going to do around that psychosis. Okay.

All right.

Do you not agree, Blair?

I do agree.

Yeah.

Dr. Spielvogel, from the medical side, what is happening to a woman's body after she gives birth? People casually say her hormones are all over the place. What does that actually mean?

I mean, that's, that sounds like a definition written by a man to describe a woman. Her hormones are all over the place. I mean, what happens? You have a complete disruption of day-to-day routine. You have obvious sleep deprivation depending on the mode of delivery, C-section versus vaginal delivery. Um, you know, what elements of healing as a result of vaginal laceration after vaginal delivery, all these things that are going to cause physical affectation. Then on top of that, you know, you have a severe hormone withdrawal. You know, not only you get periodic releases of oxytocin, you get withdrawal of progesterone, withdrawal of estrogen. On top of that, when you already have preexisting mental, mental illness, it's a perfect storm.

Okay. Well, you're an OB-GYN by trade. Uh, let's ask an actual woman. You got anything on this, Blair?

It's everything that Kenny said on a physiological level, on top of so many psychosocial changes that are happening. Um, identity is that question. I've personally found early motherhood very isolating. No one told me about that. You know, for the first week or two, people are coming, they're coming to the hospital, they're bringing you food, and then it gets very quiet. Particularly if you're used to working, if you have all sorts of purpose and functionality throughout the day. It's a very— it can be sad on top of the fact that you're told how you're supposed to be feeling. You're supposed to be glowing, you're supposed to be happy. Now, also take into account that you may have other children, their schedules, their busyness. It's a very complicated time. And I think systemically, It raises a lot of issues and challenges.

All right. How does hormones, severe sleep loss, and conditions like bipolar disorder combine to trigger a psychiatric emergency?

If this is for me, I will say, I will piggyback on it being the perfect storm. If you had any experience of this prior, the, um, the likelihood of something like this becoming more harmful to you postpartum is much greater. So if you had some depression prior, or bipolar, which is more severe prior, um, it is just about exponential that postpartum will put you in a vulnerable place. We also don't know what kind of medications you can or cannot take while you're pregnant. So that's going to have a variable within it. You'll have to alter things accordingly. Um, the lack of sleep. Now I want to just point something out with postpartum psychosis. It's not just the baby was up, the baby was nursing, I'm not sleeping well. Characteristically of this is an insomnia where the person feels energized. I'm not tired. So hasn't slept in days and also feels like I don't need to sleep. That's a distinction.

So you're saying that they haven't slept in a number of days and they're not tired. And that is a symptom of what?

Of the postpartum psychosis. That's what's going to distinguish what's happening into that more psychotic feature. than would your standard sleep deprivation, which comes inevitably with having a newborn.

Yeah, the severe insomnia is really one of the early warning signs of postpartum psychosis. And again, when you think about if the largest group is going to be bipolars and it pushes them into it, like Blair said, a manic-like state. So the sleep deprivation leads to, it pushes them almost into a mania. but then it also rapid cycles them into severe depression with psychotic features, hallucinations, auditory, sometimes visual delusions, you know, fixed false beliefs, you know, the command hallucinations as well too.

So.

How long have you been a doctor, Kenny?

30-plus years as an OB-GYN.

And you started off being an OB-GYN, right? Correct.

Okay.

So you've been doing this a long time and you are the beginning and the end in this industry. Please tell me one time where somebody with postpartum depression or psychosis has ever harmed their child.

Oh, I've definitely seen it. I've probably seen like attempted suffocation 5 times.

Really?

Mm-hmm.

So it's a thing.

Yes.

And did those people ever get well? What do you know? What— take me through one of those cases.

I'll tell you something just for your listeners as well too. If you want to see an amazing movie that really dives into the postpartum psychosis element, I don't know if Blair's seen it, but it's It's called Night Bitch and it's starring— have you seen that, Blair?

I haven't.

Oh my God, it's so good. And this woman actually starts to believe that she's a dog. And the movie does an amazing artistic job of making the viewer not sure if she's actually becoming a dog at night or this is truly a psychotic episode. I mean, in cases that I've seen that are incredibly tragic, it starts out Literally with like, it's pretty much textbook. The one that I'm thinking about in particular where severe insomnia, you're trying to treat the insomnia, a history of mental illness, a history of postpartum depression that just amps itself up. And it wasn't like, you know, suffocation to the point of follow-through. I saw no infanticide in the course of my career, thank God. But a point of just literally snapping, holding a pillow over a baby and then snapping out of it. Thank God, whether the husband was there or a nanny or whoever else. But yeah, I mean, sleep deprivation in and of itself can cause psychosis, never mind all the other elements that go along with it.

Blair, have you ever heard of this before? Truthfully, have you ever, do you know of any friends? Do you read anything?

Of course, of course. In fact, when I had my 2 babies, I was asked a screening question when I would go to my follow-up appointments about if I'm feeling sad or if I'm having any thoughts. So there was, there was some screening. I mean, there's definitely not a gap. And I would even say similar to autism, it's not that it's happening more often. It's just that the diagnostic criteria is becoming more understood, more spoken about. Women are talking to one another through social media and other venues, um, about these things that were typically hush-hush and held close to the chest.

I can add something as well too. Can I add something? I'm sorry to interrupt you.

Of course.

No, is the American College OB-GYN, ACOG, in the, in the previous time we used to deliver someone and say, okay, we'll see you in 6 weeks after vaginal delivery, 6 to 8 weeks postpartum for a physician check-in. Due to the increase in postpartum depression and postpartum psychosis, we moved that back to 2 to 3 weeks for a check-in, whether it's telehealth or an in-person check-in or home visits. So home visits have become much more prevalent as a way to be able to check in on people in their environment, see if they're taking care of themselves, taking care of the baby, taking care of their house as well too.

Yeah, I gotta tell you, I'm having a hard time with this. I mean, I'm really having a hard time with this. I'm sure that this occurs in certain cases, okay? I get it. But this sounds like bullshit to me, okay? It just does. This woman had 3 children, 3 of them. And killed each one?

Mm-hmm. With an exercise band.

Do you know how long that takes? 3 running, running down 3 kids and choking all 3 of them? I mean, that had to have taken at least 5 to 7 minutes.

That is so tragic. It irks all of us. We feel it in every cell of our bodies. But if we just judge it, we're not going to learn anything. It's important that we're curious what could bring someone to do something like this. It's the only way we'll get some information and hopefully be more preventative in the future.

I agree.

I think the heinous nature of it, like you said, the heinous nature of it in someone who was a labor and delivery nurse with zero history of violent behavior, no domestic violence, nothing but a, a just a A very impressive history of, you know, multi-visits for mental health, hospitalizations for mental health, 50-plus medication trials for mental health. I mean, this is clear. That's why this case for me really kind of, you know, it really gives me great pause. I would not want to be the jury on this case.

I would not.

Well, how about Constance Fisher? Do you know that case? It was back in the '50s, '60s. Woman committed the same— a very similar crime, killed her 3 children, killed her 3 children, was hospitalized, and then attempted suicide, was hospitalized for 5 years only to be released to her husband, have 3 more children, and do it again. Now, she, on the other hand, was paranoid schizophrenic, which is a very different diagnosis. Mm-hmm.

Susan Smith. I mean, that's another one, like drove her minivan into the lake and killed her 3 kids.

What happened?

That was Susan Smith, I think. Yeah, she drove her minivan into a lake with her kids in the car and they drowned. Purposefully.

And did she die?

No, she went to prison.

Did her kids die?

Yes.

I, I, I'm literally flummoxed. I don't know what to say about this.

So many barriers to treatment. I mean, think in the UK, they have MBUs. Is that right? The mother-baby units in the UK where you can literally have a mother and when it's safe, she's being treated and the baby is in the unit and they can have bonding together. Because what could happen, like, let's look at the whole picture here. Not everyone has built-in support. support systems. Let's say a mom's symptomatic but the dad's working and there's other kids, and they're like, well, who, who would watch the baby? Um, all that stuff really gets in the way of people getting the help that they need. I think in this case— correct me if I'm wrong— but Lindsay was texting her mother and someone else in her tribe like, please come stay with me, please come be with me. Yeah, it's very sad.

This is a case I— look, To me, the tragedy is I look at it as somewhat of a failure of the system. I don't pretend to understand the minds of the providers that were in this case. It's incredibly challenging. People can be on their best behavior in the course of a doctor visit and go home and then get under, you know, the haze of twilight and sleep deprivation and the triggers that are in the house and get to places if you're already psychotic to begin with. I mean, I've talked to schizophrenics that are having active auditory hallucinations and they'll speak to me in the most clear, coherent manner that I would never be able to detect that. So I don't pretend to understand the challenges that her care team was undergoing. It seems to me that she was enough at risk that having some sort of chaperone was a good idea. I mean, I understand you have your husband there. You have a husband who's involved. you imagine that there's no way that anything can happen, but I mean, clearly there is.

And there's always two sides to a story, right? She called all her friends, she called her mother, called everybody, come hang out, come be with me, I need support, whatever. And at the very last second—

Doesn't sound like a premeditated murderer, does it? It doesn't.

Well, it doesn't until you send your husband, uh, to, uh, grab some stuff that's so far away that You know, perhaps that's the command hallucination we were talking about, which is basically an audio.

It, it, it tells you what to do, and it could be something like, do this in order to protect them from the devil. It could be so compelling.

Do you know what scares me more than anything, man? What scares me more than anything is 2 things. Number one, if she really is if this is true and she really was this sick, okay, then the victim in this is her, okay? Because she's the one who's got to live with what she did, okay? Uh, she'll never—

She's paralyzed as well. She's paralyzed. You think about actual punishment of the crime, I mean, that's right. That's a pretty horrible jail to be in for the rest of your life.

Oh, I'd rather have that than the knowledge if you ever get well, or those brief moments where you are well, right? Having to, knowing that you strangled your 3 children. I'd rather be, I'd rather, I'd rather be in perpetual hell than have to think about that.

I'm surprised she didn't have the ECT. I really am.

What's an ECT?

Uh, electroconvulsive therapy. I mean, it's very effective in many situations of severe depression, even with psychotic features.

How do you know she didn't have it? I don't—

I didn't see in her list of treatment that she had had ECT. I don't—

I don't know if it's chatter. It'd have to be fact-checked, but I heard the jury wanted to see all the meds, and they learned that all the prescriptions were filled, like that she hadn't actually taken them. I don't know if it's true. Did you hear that? Anyone else?

Yeah.

Oh, that would be a good fact for her.

No, I think that would work against her because they're saying that she was over and improperly medicated as part of her defense. I don't think that would bode well for her.

Uh, listen, her lawyers are, you know, there's one of two things that are happening, right? You're either overmedicated or undermedicated, and they both produce the same things, right? Right. Yes or no?

Yeah.

I mean, this idea, you know, we sit in rooms and we screen people by saying, do you think about harming yourself? Do you think about harming others? No person is going to, in a small exam room, in a 15-minute postpartum visit, admit to that. I mean, this is yet another way that this— I'm not blaming doctors. I blame the system in terms of how much time we're given to see patients, to do these kind of effective screenings. Hey, look, I could sit here on a total podcast and tell you all the ways that the healthcare system set itself up for this to occur, which is shrinking insurance reimbursements. Doctors don't make enough money, therefore they cram more patients in, therefore they have to do more deliveries, then they have less time to see patients. Then there's more doctors working in a practice because no one wants to be on call. So you don't know your patients well. So when a person comes in who's an absolute stranger, you can't detect a change in their behavior in one 15-minute visit. So, you know, we reap what we sow. And this is where we're at.

Yeah.

Hey, this is dark. This stuff. There's no light.

This is the worst. This is the worst.

Yeah.

This is—

I mean, and I'm getting pissed at myself because the more I hear about What's going on? Because I didn't know anything about this until an hour ago. I mean, I'm not filling my head with this nonsense.

Okay, dark.

No, it's just it's I hated it. And then I I come in here with the preconceived notion of you know F you you're going to prison you're going to prison forever I hope you rot in hell. Okay, and I go from that to listening to all of this and now I'm just.

aggravated. Right, right.

And there's just no way to, to make sense of it. There's just no way to make sense of it. You can't blame it on the system. You can't. The system didn't fail this per— yes, over time, around the margins, and slowly but surely, a death of a thousand cuts. That's been happening in every industry everywhere, okay? That's just the way it works, okay? But this thing, I, I don't know. I don't know.

There's a true gap in information. Women were left out of research for so long because we cycle. We're really bad control groups. We're just bad control groups. So like, you know what, we'll study the guys because they're like more even-steven.

No doubt.

So we're like behind at least 40 years in, in, um, Having research on how hormonal fluctuations impact things. I mean, I just learned how where a woman is in her cycle, how alcohol impacts her differently depending on where she is in her cycle. And I've been working in this field. I feel like I should have known that.

Women's health takes this, gets the shaft in every— I could tell you stories over my 30-plus year career in the emergency room about the treatment of women versus men.

Even Ambien, remember that? Ambien, they didn't— they had the whole, um, dosage wrong for women. So men were getting a great night's sleep. Meanwhile, women were like standing in the middle of the street at midnight in their robes eating pasta, right? Oops, sorry, wrong dose. We didn't actually study that.

Blair, when someone is psychotic, what is happening to their perception of reality?

There is no connection to reality. You know, if someone is psychotic or even delusional, you don't want to engage in the argument of, oh, that's not happening. And typically in the throes of it, you are unaware that you are in psychosis. So it is a disconnection from reality entirely.

Can someone be experiencing psychosis and still have moments where they appear completely normal, carrying on a conversation, caring for their children, or going to an appointment?

Yes, this can happen. Part of the nature of this is its rapid cycling. And Dr. Kenny mentioned earlier sundowning syndrome. When the sun goes down, the whole picture can really change. So yes, both can be true. Someone can be active in psychosis and have glimmers of coherence and lucidity.

Explain the sundown syndrome again. What is, what is that?

This happens across many diagnoses. I'm even thinking dementia, Alzheimer's patients, where once the sun goes down, particularly if you're in an institution, but it can happen when you're home as well, the perception of reality just distorts. Someone becomes, um, can have hallucinations that then dissipate when the sun comes up. I can't— Kenny, can you elaborate more?

Yeah, no, that's very good. I mean, generally it's a disorientation. It's, it's precipitated by sunset to sundown. We see it a lot in the elderly, in, uh, assisted living and senior living places. But again, with postpartum psychosis, Anything that triggers that, you know, it's like fear of the night is, is a pretty classic term in the postpartum period because with nighttime generally comes sleeplessness, loss of control, less people around to support, and it's absolutely a precipitating event for psychotic features in someone who is postpartum psychosis, you know, as a diagnosis.

I didn't even know that was a thing. I sometimes get sad at night and I've always sometimes gotten sad at night. Like the day's over.

And then think about, so let's say someone's going through something, but the evaluator, the physician, the clinician sees this person at 10 AM, their best self, took a shower, hygiene's on point, right? So both things can be true.

Out of the house too, out of the environment.

What is command hallucination? If someone hears a voice telling them what to do, does that mean they have no control over their actions? What is this?

thing. It's exactly how it sounds. It is a hallucination, a voice that is telling you what to do, commanding what to do. So it's not something that you're negotiating with and having a conversation with. It is an absolute—

It's a demand. It's a demand. Okay.

Auditory hallucination, delusions, they have these fixed false beliefs, like The kids are killing me could, could have been her false belief. Um, they often involve— in postpartum psychosis, they often involve the baby. Feelings of persecution. These command hallucinations often tell the person to harm themselves or to harm, uh, the infant. Disorganized thinking, you know. Yeah.

I can't stop thinking about this one.

She's, she's obviously over her She's a labor and delivery nurse.

I know.

It's—

I know. I know.

That to me shows me how ill she was. No one has more insight into what her resources are or what's out there or just a friend circle of capable people than a labor and delivery nurse.

Kenny, from your experience caring for women during pregnancy and after childbirth, What physical or behavioral changes might a doctor notice first?

I mean, I would say, you know, if I just look back at like people coming in and reporting symptoms, sleep disturbance is number one. So the inability to sleep, even when the kid's sleeping, just the heightened anxiety around SIDS, around, you know, God forbid, like this is a preemie baby as well too, who has an increased risk of SIDS and, um, You know, and then you have a complicated pregnancy, complicated delivery. So then there's going to even be a heightened sense of anxiety around the child. So just because the child's sleeping doesn't mean that the patient's therefore sleeping. Then you have maybe a poor, you know, the relationship gets tense. I can observe the couple and how they're interacting with one another. You get a husband who's pressing a person to be intimate with them. You know, that in and of itself is a whole other deal. I was actually thinking of The Valley, that reality show where like they really told the story of like women, 2 women on the show were postpartum and how one of them was truly struggling through postpartum depression. And it was, it was pretty compelling to watch. But anyway, yeah, so the, the insomnia is a big part of it.

Depression. I never heard a patient in 30-plus years In as many deliveries as I did, say, I think about, uh, occasionally maybe would say, I think about hurting myself, never about hurting the baby. I never heard that.

Um, and where does shame come into filtering this stuff too? Like, yeah, I know it out loud. And as you said, we used to have a relationship with our providers. We used to have that ongoing intimacy. And now it's like, sometimes people's back is towards you and they're just like doing their notes.

Totally, totally. As a solo provider, I can tell you that my clients, my patients felt comfortable talking about those things. I had them put their clothes on. We sat in my office. Nobody talked to me in a gown. And really like being mindful of that as a physician, of putting people in the best possible position to actually open up to you is super important in these interactions.

Right, right. With your legs on stirrups. How many? It's like, let's have a real talk. I don't think so. It's so vulnerable.

Without commenting on Lindsay Clancy specifically, how can medications complicate postpartum psychiatric symptoms?

I'm not a psychiatrist. I don't pretend to be one, but, you know, I have a ton of experience in the work, um, even in this work in addiction as well too. To see the challenges in trying to teach— treat someone with postpartum— I mean, bipolar disease in and of itself. You push them into mania with the wrong drug, you push them into depression with the wrong drug, then you essentially have a moving target that you're trying to adjust medications. And then you have a patient who's not capable, if they're already in a psychotic state, to give you an accurate history of where they're at and whether medication working. And Blair, you brought up a great point, which is whether or not they're even taking their medication. That's where, you know, to me, you know what solves so much of this is home visit. Because if we have regular home visits, you're able to keep an eye on a person, see how they're interacting in their own home environment, which is everything and tells you everything. When I was in medical school, I was part of an outreach program where medical students would go to patients' houses postpartum.

And I'm not— this— the living situations that I saw were pretty grim at times. So yeah, I think— and then side effects of these medications are, we know they can be severe. So you can be trying to do good and push somebody into a state of, you know, even more severe depression and maybe a heightened sense of psychosis and auditory hallucinations. So, all right.

Talk to me about these Talk to me about these home visits because, I mean, where are we, in some rural back town in Missouri?

No, this was in Denver. This was in Denver.

Okay. Nobody does home visits anymore. Nobody. Do you know what else there isn't anymore? A milkman. There's no more milkman.

Well, doctors, we do have, there's nurse practitioners, there's There's midwives, there's lactation specialists that will do home visits and work with patients. I think I, and honestly and truly, I do think that we are doing a better job and have a heightened awareness around postpartum depression and psychosis and how poorly a job, how poor a job we did previously. Like I said, the screening protocols moving up to 2 weeks postpartum. And telephone check-ins and home visits with mid-level practitioners has definitely become more prevalent. So I'm not throwing the system under the bus. I'm not.

Okay. I am. I am. Because, you know, who pays for that? A lot of these people are, are, are without means. Okay. Who pays for somebody in healthcare to swing by the house and do a house visit? Like, how is that a thing?

I mean, there were state systems that do it.

The answer is nobody, because even if you get— let's say, let's say something like that is available in Medicare and someone's got Medicare, right? Okay, how long is it going to take to get somebody down there? What level of person are they sending? Okay, and on and on and on and on and on and on. Okay, we, we, we identify— I have no confidence in that.

We identify at-risk people in the hospital based on how they're behaving postpartum, based on their history, based on their social support network. And those people are flagged, and we do have people that will check in and do home visit regardless.

Okay, that's a different story when you flag somebody, right? And they've got a newborn at home. Yeah, you're gonna, you know, that's—

I'm sure this woman was flagged though. I'm sure she was flagged.

Well, I don't know. Did anybody come by the house? Did she get a— that's excellent. Did she? Thank you. Did she get a home visit?

Yeah, I don't know.

Okay, if she didn't get a home visit, then it's bullshit. Because if anybody deserved a home visit, it would have been her, right?

You would think so. But you would also say like, this is labor and delivery, you could see where she would fall through the cracks. Because she's a healthcare professional. Why?

Explain that to me. Oh, because they just naturally assume she's a healthcare provider. So like bartenders don't get drunk, like that kind of thing, or hair— or barbers don't get haircuts, that kind of thing. Doctors don't get sick. Lawyers don't have— lawyers don't have legal problems.

I heard a statistic that was pretty troubling, that the average— it takes the average woman 5 years to see a general practitioner after having a child.

I wonder why that is.

Well, you have the child, then you have their doctor's appointments, their appointments, every— it's everyone else's needs. And we've been even programmed that we get like an accolade by putting everyone else's needs first.

Which is so crazy because this is a sector of young women, young women who get gestational hypertension, preeclampsia, gestational diabetes. They are It is a fact that they are at an elevated risk of cardiovascular disease and stroke and hypertension moving forward in their lifetime. Those are the people that absolutely have to get in sooner and be identified and, and activate a prevention protocol.

There's a woman in my community actually who was pregnant, about 7 months pregnant with her 4th child, and was diagnosed with an aggressive leukemia. They had to induce the labor. A lot was going on. And I was talking to the husband and I was like, you know, this scenario. And he said she was feeling some symptoms, but had she not been pregnant, she probably wouldn't have gone to the doctor.

Right. That happens a lot.

And that stood out to me. So they actually see that baby as her savior. And the, and the mother-in-law was an overnight nurse who had retired for years, and they were always giving her shit for not adjusting her schedule. And she would still stay up in the wee hours of the night and go to bed at 5 in the morning. And she was the one feeding that baby all through the night so the dad could be home with the older children. And the whole community descended upon them. I have goosebumps.

I diagnosed melanoma in a 32-week pregnant woman who was 30 years old, first baby, had to be induced early, and she died 3 weeks after delivery. And my father, who spent a career as an oncologist, said to me, I said, I'm gonna go to the funeral. And he said, do not go to the funeral. You'll be haunted for life. He's like, I don't go to the funerals of my patients. It's too much. And I went to the funeral and I saw that baby in the arms of the aunt and I'll never forget it as long as I live. It was the most heartbreaking experience. I mean, since then I've had other heartbreaks, but that's pretty horrible. Yeah.

How do clinicians determine whether symptoms are psychiatric, Medication-related, substance-induced, or a combination of some or all of them?

That is a delicate dance, and you do need the luxury of time. People are not at baseline coming into Carrera if they've been on a run using cocaine, for example, and I look at them and all of their symptoms align with major depressive disorder. That's not a fair gauge because sleeping more, eating more, all of that is part of the detox from the substance. So we really need to get a baseline. And, um, I was saying earlier how people and family members in particular really want to get a diagnosis pretty soon, and you have to pump the brakes on that. So it's complicated. You do want to have a clear history.

Ah, you just brought up the money shot. You did great. Now let's talk about that. Let's say it wasn't postpartum, it was meth-induced psychosis. Now what?

Yeah, I was involved in a case in South Carolina my first year out of residency. I don't know if you guys remember this. You Blair, you were probably like a zygote. But, um, there was a woman who got charged with murder because she used crack during her pregnancy and had a placental abruption and delivered a baby that died. So they charged her with murder and she went to prison.

That's too bad because those people are scumbags because That's not her fault.

See, there you go. Now you're coming from a— isn't this interesting? So you're coming from a very different empathic understanding of the mindset of a person who is under the throes of addiction in that moment, and you're saying they have no control over it, right?

Well, not only that, it wasn't just because— it was not only because They were doing the drugs. It's because they didn't intend— they didn't physically harm that child. There are, there are—

Yeah, they did. Of course they did. They didn't use— if they didn't use, the child wouldn't have died. You don't think that they, they didn't understand the implications?

No, they didn't know.

Okay. I'm playing devil's advocate, by the way. Well, fine.

But they didn't know— she didn't know she was going to kill the child by smoking crack. Okay. It's pretty— it's pretty certain to, you know, I mean, you know, you're going to kill the child.

What if it's documented in her medical record that says that if you continue to do this, that you could potentially endanger the life of your unborn child, then what?

That's an excellent question. Then it's—

Let the record show I got Richard Tate to be speechless. No, you did not.

No, no, I'm being mindful.

Okay. Let the record show I got Richard Tate to be mindful for 3 seconds.

Okay, that's fair. That's fair. All right.

This is so fun. Keep going.

I know I'm having a good time too. Um, but mostly because I'm holding you hostage and you've got patients to see and I don't care. Um, that's an excellent question because then that has to do with being in the throes of addiction and then that goes to, well, if you're, if you're drunk driving behind the wheel of a car and you run into a family of 4, it doesn't matter. Okay. Because it's illegal to drink and drive, but it's also illegal to smoke.

Mm-hmm.

So it's, it's, it's very— this isn't something that I'm going to be able to To unpack on a podcast.

But isn't that what involuntary manslaughter is all about? You did it, you didn't mean to, but you did it. Is it voluntary if there is a command hallucination, which by definition is commanding you?

Right. No, I understand that. I understand that. That's why it's so interesting. But, but there's certain elements to the law, right? And what that entails. So What is voluntary, right? And so that's going to end up probably being the question, you would think, right? Is it voluntary if you're being commanded?

That's why I would imagine that a woman who's under, uh, you know, been afflicted by postpartum psychosis, not depression, would have an insight and understanding into what someone is capable of if left untreated or unchecked.

New mothers are expected to be exhausted. How do you distinguish ordinary exhaustion, Kenny, from sleep loss that has been— that has become medically or psychiatrically dangerous?

Again, I think if it's persistent night after night, if it's persistent even in the face of help like a night nurse or a husband who's getting up to feed the baby. Um, you know, it goes beyond just postpartum depression, which is sadness, emptiness, or hopelessness, loss of interest, loss of pleasure in activities, fatigue, or loss of energy. Those are, you know, insomnia or even hypersomnia, which is where somebody just sleeps all day. You know, that's also— that fits within the definition of postpartum depression. So all those things are under the The umbrella of postpartum depression. The psychosis comes— Blair alluded to it earlier, and it's an important component. It's the sudden onset of symptoms that are psychotic in nature that we've already exhausted, I think, in the course of this, uh, auditory, visual hallucinations, compulsions, all of that. Um, and generally, like I said, it is sudden in onset. I hope that answered the question.

What if she says, I'm fine, leave me alone? When should family respect that, and when does safety require getting help anyway?

I mean, I would say if you have any evidence of postpartum psychosis, any documented evidence, then it requires further— if someone has suicidal ideation or homicidal ideation or infantile, uh, you know, Infant homicide ideation, it absolutely requires probably hospitalization and coordinated care.

Right. And at this point, it's in such a crisis mode, things like boundaries and respect are going out the window. We all need to huddle around the child and what's in the best interest of the child at that point.

Yeah. And the mom.

I mean, the mom, if she's, if she's got suicidal ideation, She needs to be, you know, she needs to be, uh, hospitalized. I mean, that's, that's a no-brainer. It's very difficult to do. I can think of one patient in particular, getting her in, getting her into UCLA was such a nightmare. And we, you know, we were in Long Beach, but to get her into UCLA, which was one of the few—

Why?

Just, it's one of the few facilities that'll actually take these women. So it's difficult to find a psychiatric hospital that is willing to take women with postpartum psychosis, especially Blair alluded to it as well. You still want to have mother-baby bonding. So to try to have any kind of mother-baby bonding under a supervised nature, obviously, um, yeah, it's so much—

Very black and white. It's very black and white right now. And I think we can do better with having those mother-baby units.

So, so that's what it is. It's a mother-baby unit at UCLA Psych where they will take care of the mother, where, and, and that's part of the psych treatment. You have the baby, right? So that you're right. No, it's, it's got to be.

I mean, yeah, UCLA. I don't know that UCLA has that in their psychiatric unit. It's just hospitalization of mom.

Yeah, that needs— if that's not done, that needs to be done. Because you would think if a woman was having a problem after a crisis after birth, mm-hmm, couple things. Number one, you need the baby. You need supervision to make certain that they're taking care of the baby, right? Not harming the baby. Obviously, I didn't know that was a thing.

Okay.

Until this. uh, thing happened, uh, with this case, this Casey case. Yeah, this is horrible.

This is— And that's where it comes in, where like detection and care can really be postponed and put off because people are like, but who's gonna take care of the baby there? It's like, it seems so far-fetched. We've seen this in Carrera. I've seen people come in, women come in, mothers who deserved, needed, even wanted treatment Months prior to actually getting it because there was so much organization that had to go around the childcare and the care of the home and all of it to even allow her to, to go and get the care she needed.

Yeah. What will move the needle on this thing? How do we get this thing handled?

I think the easiest way is like I've been alluding to the whole show is Home visit. Home visit gives the insight that a doctor's office does not. And I think that in and of itself, if we look, there's a lot of different failures to the system. This is a very quick, down and dirty, easy way, relatively cheap in order to keep a closer eye on people who are at high risk.

What do you mean relatively cheap? Oh, stop. Stop. This is insanity. What do you mean relatively cheap? You're gonna go ahead and do a home visit for everyone that has a baby?

At risk. At risk. So the people who are flagged—

Can't you throw out the— like, put the— like, there's got to be soldiers. In fact, I feel like most medical practices these days is one MD and a whole lot of nurse practitioners, right? Reasons that Dr. Kenny was saying earlier— doctors aren't getting paid as much as they used to. That whole intimacy. So it's like there's the soldiers and then one person in charge. Let's just send the soldiers out.

Yeah, could be medical students, nursing students, doesn't have to be an actual even licensed professional who's just doing home visits.

So, okay, well, if it's just for people at risk, I think that's amazing. I think that's a great idea. And that doesn't happen now?

I mean, it happens in some, in some hospital systems. Kaiser is pretty Pretty good initiatives around maternal health and wellness. Um, MemorialCare system is okay, not great. I don't know, but I'm just thinking of the hospital systems in our area.

I think we need to keep talking about it too. In fact, if you look at the language, this has been woke. Look at the word hysterical. Hyst— what's the etymology of this? Hysterical— the uterus is making someone crazy. This isn't new. We're just talking to each other. Even like perimenopause, a term that I hadn't even heard a few years ago, is all I hear. Granted, I'm a 41-year-old woman, so there's probably the algorithms found me, but still, it's, this isn't new, but we, the information, the gaps in the research, the fact that women weren't included in the research for all the variables of cycling and all of that, we need to do better on that.

And I hate the phrase perimenopause going on record. Because peri implies before and after. It's around menopause, and the woman moving towards menopause is very different than the woman who's postmenopausal.

But I'll tell you this, I've had changes in my own hormone and my own cycles, and when I spoke to my OB about this, she said, stop listening to podcasts.

I felt—

I mean, I didn't appreciate that answer.

I wouldn't appreciate that answer either. There's great information to be had through podcasts.

If a new mother knows something isn't right or her family sees her changing, what should they do today?

I mean, I can absolutely contact provider, contact your circle, your network of people, make sure that eyes are on the patient, eyes are on the kids at all times. At all times means day and night. If you can't get an appointment with the provider, yeah, I mean, bring her in, wait in the waiting room, get to be seen. I mean, as providers, if we get those calls, we have to do a better job of triaging these people appropriately. But the, you know, it takes a village. It takes a village. So you can't expect that just a single OB-GYN is going to be handled. be able to handle a complex case of postpartum psychosis.

So what you're saying in, in essence is it's, you got to get your entire team on board, your, your psychiatrist, your, um, your therapist, your, uh, uh, primary care physician, the OB-GYN. I mean— Lactation specialists, postpartum nursing, like coming to the house, like Or whichever ones of those you happen to have, you have to do it, not just one doctor, you do as many of these people on your team as you can. And that, okay, good. That's, that's good advice.

I mean, if we have sober coaches or we have, you know, sober companions, there's no reason there's far fewer postpartum psychosis cases. Where we couldn't have, you know, a postpartum companion.

And I would just say for families that you're not expected to know what to do. And that's part of the asking for help piece. And if you see something, not just say something, but do something, take some action. You're, you're not expected to know how to handle this, just like we tell our families at Carrera, you're not expected to know what to do. That's what we're here for. Please lean on us.

That's really good.

That is good. All right, guys, what did we leave unsaid?

I think this is just completely tragic. I think it goes without saying.

I guess what the, the real ending to this is, and how everybody would feel, is if it's true, we want this woman to get the help. That she needs and, and God willing, she'll have some relief at some point and be able to forgive herself, get healthy and move on. Not likely. Okay. But that's, that would be my wish. If obviously, and we don't know, uh, uh, she was actually ill and had no idea what she was doing. If it's one way, we want the complete polar opposite of if it was intentional. And that's, that's why this is in a nutshell grabs me so hard.

I wanted to know too, Richard, when we first came on, you were like, you know, so adamant about one way and you, once you heard some more information, you actually, there was a lot more flexibility in the way you were thinking about it.

Yes, it was. At the beginning I came in, I was like, guilty, in jail, goodbye. Okay.

Long history of mental illness. No boy, you know, all the stuff that you hear these people, some secret relationship where they want to free themselves from the kids in order to be available to this person in some sort of delusion. No history of violence, no history of crime, a long history of mental illness, and and psychotic features. It's like, it's totally tragic and horrifying, but I have great empathy for her in her position.

Thank you for coming today, and, uh, everyone, we'll see you next Tuesday.

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