In January 2023, Lindsay Clancy, a former labor and delivery nurse from Massachusetts, killed her three children, five-year-old Cora, three-year-old Dawson and eight-month-old Callan, before attempting to take her own life. She survived the suicide attempt but suffered injuries that left her paralysed from the waist down.
Clancy is now facing trial for three counts of first-degree murder. Her defense does not dispute that she caused the children’s deaths. Instead, it argues that she was experiencing a severe psychiatric illness and was not criminally responsible for her actions. Central to that argument is postpartum psychosis, alongside alleged bipolar disorder, extreme insomnia and complications surrounding her psychiatric treatment.
The prosecution has presented a different interpretation, pointing to evidence that Clancy was organised and deliberate before the killings. Whether her mental state met the legal standard for lack of criminal responsibility is ultimately for the jury to decide.
But beyond the courtroom, the case has brought attention to a psychiatric condition that remains relatively rare and widely misunderstood: postpartum psychosis.
What is postpartum psychosis?
Postpartum psychosis (PPP) is one of the most severe psychiatric emergencies associated with pregnancy and childbirth. It is different from the “baby blues” and from postpartum depression because it can involve a loss of contact with reality.
The condition is rare, affecting approximately 1 to 2 women in every 1,000 births, or around 0.1–0.2% of mothers.
Symptoms can appear suddenly and may include hallucinations, delusions, paranoia, severe confusion, disorganised thinking, extreme mood changes and profound insomnia. A person may hear voices, believe things that are not true or become convinced that they must act on a particular belief.
Because insight can be impaired, someone experiencing psychosis may not recognise that they are ill.
PPP is considered a psychiatric emergency because the risks of suicide and harm can increase significantly when psychosis is present. Immediate psychiatric assessment and treatment are therefore essential.
How is it different from postpartum depression?
The terms are often used interchangeably in everyday conversation, but postpartum depression and postpartum psychosis are very different conditions.
Postpartum depression is much more common. It can affect approximately 1 in 7 women, although estimates vary depending on the population studied and how the condition is measured. Symptoms can include persistent sadness, anxiety, hopelessness, guilt, loss of interest, difficulty bonding with the baby and thoughts of suicide.
Postpartum depression does not automatically involve a loss of reality.
Postpartum psychosis does.
A mother experiencing postpartum depression may have an intrusive thought such as, “What if I accidentally hurt my baby?” and be horrified by the thought. She generally understands that it is unwanted and does not reflect what she wants to do.
In psychosis, hallucinations or delusions can instead feel completely real.
This distinction is important because having a disturbing thought is not the same as wanting to act on it, and intrusive thoughts alone do not mean someone is psychotic.
When does postpartum psychosis happen?
PPP usually develops very quickly, most often within the first two weeks after childbirth, although symptoms can appear later.
Its timing is one reason Clancy’s case has attracted particular psychiatric attention. Her youngest child was eight months old when he died, considerably later than the period in which postpartum psychosis most commonly appears.
The defense’s argument therefore involves more than simply claiming that childbirth itself caused psychosis. It has pointed to a broader psychiatric deterioration involving possible bipolar disorder, severe insomnia, postpartum mental illness and medication changes.
That distinction matters because postpartum psychosis is strongly associated with bipolar disorder.
Who is most at risk?
Although postpartum psychosis can occur in someone with no previous psychiatric history, certain factors significantly increase the risk.
The strongest known risk factor is bipolar disorder. Women with bipolar disorder have a substantially increased risk of developing psychosis during the postpartum period.
A previous episode of postpartum psychosis is another major risk factor. Someone who has experienced PPP after one pregnancy has a considerably higher risk of experiencing it again after a subsequent birth.
Other factors associated with increased vulnerability include:
- A personal or family history of bipolar disorder or psychosis
- Previous postpartum psychosis
- Severe sleep disruption
- Rapid hormonal changes following childbirth
- Certain pregnancy or delivery-related stressors
- Discontinuation or changes in psychiatric medication
Importantly, PPP is not simply caused by being tired or overwhelmed by motherhood. Its development is believed to involve a combination of biological, genetic and environmental factors.
Why does childbirth trigger it?
There is no single explanation for postpartum psychosis.
Researchers believe several factors may interact.
After childbirth, levels of hormones including estrogen and progesterone fall dramatically. At the same time, sleep patterns can change substantially. For someone with an underlying vulnerability to bipolar disorder or psychosis, these biological and environmental changes may contribute to a psychiatric episode.
Genetics also appear to play an important role.
However, researchers are still studying exactly why some women develop postpartum psychosis while others do not.
It is therefore too simplistic to say that PPP is caused by “hormones” or by sleep deprivation alone.
What does psychosis actually look like?
One of the reasons postpartum psychosis can be difficult to recognise is that it does not necessarily look the same in every person.
Symptoms can include:
Hallucinations: Hearing voices or seeing things that are not actually present.
Delusions: Holding beliefs that are firmly maintained despite evidence that they are untrue.
Paranoia: Becoming convinced that other people are trying to harm the mother or baby.
Confusion: Becoming disoriented or having difficulty distinguishing reality from imagination.
Extreme mood changes: Rapid shifts between depression, mania, agitation or emotional instability.
Severe insomnia: Being unable to sleep for extended periods, sometimes despite being exhausted.
Disorganised behaviour: Acting in ways that appear increasingly unusual or difficult for others to understand.
The symptoms can also fluctuate. Someone may appear relatively coherent during one interaction and become severely confused or delusional later.
That does not mean every quiet or organised person with postpartum mental-health problems is secretly psychotic. It simply means that psychosis cannot always be identified from a brief observation.
Why can it be missed?
A major challenge in diagnosing postpartum psychosis is that new mothers already experience enormous changes in sleep, mood and behaviour.
Exhaustion can look like confusion. Anxiety can look like agitation. Depression can involve suicidal thoughts. Intrusive thoughts can be frightening without being psychotic.
A patient may also fail to disclose hallucinations or delusions because they are frightened of being judged or having their baby taken away.
In some cases, the person may not realise that their experiences are symptoms at all.
This is why information from partners and family members can be extremely important when assessing someone whose behaviour has suddenly changed.
Can postpartum psychosis be treated?
Yes.
PPP is treatable, but because it is a psychiatric emergency, treatment needs to happen quickly.
Hospitalisation is often required so that the mother can be kept safe and closely monitored. Treatment can involve antipsychotic medication, mood stabilisers and other psychiatric medications depending on the individual’s symptoms and diagnosis.
Sleep is also an important part of recovery.
With appropriate treatment, many people recover from postpartum psychosis. The condition is not a permanent state of psychosis, although some people may subsequently receive a diagnosis of bipolar disorder or another psychiatric condition.
For women who have previously experienced PPP, doctors can also develop preventative treatment plans around future pregnancies and the postpartum period.
What does Lindsay Clancy’s case teach us?
The Clancy case should not be interpreted as evidence that postpartum psychosis causes mothers to kill their children. The vast majority of women experiencing postpartum depression, anxiety or other perinatal mental-health conditions do not become violent.
What the case does demonstrate is the difficulty of recognising and evaluating severe postpartum mental illness.
Clancy had received psychiatric treatment before the killings, yet the clinicians who treated her did not all reach the same conclusions about her condition. The defense argues that her illness was more severe than it was recognised to be, while the prosecution argues that her behaviour demonstrates awareness and intent.
That disagreement reflects a much broader problem in psychiatric care: mental illness does not always present in an obvious or consistent way.
The case has also highlighted the importance of distinguishing postpartum psychosis from postpartum depression, intrusive thoughts and ordinary postpartum exhaustion. Recognising hallucinations, delusions, extreme behavioural changes, severe insomnia and symptoms of mania or psychosis can be critical to getting someone appropriate treatment.
Ultimately, the legal question in Clancy’s trial is whether her psychiatric state affected her criminal responsibility. The medical question is different: what illness was she experiencing, how severe was it, and could it have been recognised and treated differently?
Postpartum psychosis is rare, but its rarity should not make it invisible. For the women who experience it, and the families around them, recognising the warning signs early can be life-saving.
