Postpartum Psychosis Is More Complex Than the Lindsay Clancy Trial
Trigger Warning: This article discusses killing and suicide. Some readers may find this distressing.
I have been watching the Lindsay Clancy trial unfold over the past few weeks, with growing unease. Now, after weeks of testimony and intense public scrutiny, the proceedings have ended in a mistrial.
Before I started my PhD, I knew very little about postpartum psychosis (PPP). I had briefly studied it during my Neuroscience and Psychiatric research bachelor’s and master’s degrees. But it wasn’t until I co-led the PRAM-P cohort study (which followed women at risk of PPP from pregnancy up until their children were between 6-12 years old) that I truly started to understand the complexity and severity of this psychiatric disorder. And yet, I still have so much to learn.
I am not a psychiatrist or legal expert, nor have I watched every moment of Clancy’s trial. I am not here to judge what its outcome should have been.
What I can comment on is how PPP has been discussed around the case. The trial may have ended without a verdict, but the conversation around it has revealed something important: PPP remains profoundly misunderstood.
The Complexity of Postpartum Psychosis
If you take one thing from this piece, let it be this: PPP is an extraordinarily complicated and variable disorder. It can develop rapidly and its presentation can fluctuate dramatically. Also, it is not postnatal depression.
PPP remains relatively under-researched. It is rare, and people are often extremely unwell when researchers would need to recruit or assess them. I saw these challenges first-hand during PRAM-P: some participants became too unwell to continue, while for others, their illness made reconstructing aspects of their clinical history difficult. Our evidence base is therefore still developing. I know that my colleagues who first assessed these women when pregnant and postnatal also found it challenging. A colleague, Dr Katie Hazelgrove (Postdoctoral Research Associate), noted, "Although many women were highly motivated and willing to participate, participating in the research often meant sharing deeply personal experiences during an already complex and vulnerable time."
Even its classification reflects this complexity. During the Clancy trial, psychiatrist Dr Avram Mack testified that PPP has not been approved as a distinct diagnosis by the American Psychiatric Association (APA). This requires some context. PPP is not a standalone diagnosis in the DSM-5-TR, widely used in American psychiatry; instead, postpartum psychotic presentations are classified within existing mood or psychotic disorders.
The UK predominantly uses the World Health Organization’s ICD-11, which explicitly recognises mental or behavioural disorders associated with pregnancy, childbirth or the puerperium, including those with psychotic symptoms.
Neither system, however, recognises PPP as a distinct category, something perinatal researchers and clinicians are campaigning to change.
This illustrates a broader challenge in psychiatry: we need diagnostic categories and “typical” presentations to recognise, study and treat illness, but these categories are imperfect. The absence of a distinct diagnostic label does not mean a disorder is not real.
A Description of Postpartum Psychosis
PPP is rare, affecting 1-2 out of every 1000 births. As mentioned above, PPP is part of the bipolar spectrum, and indeed women with bipolar or schizoaffective disorder and/or previous history of PPP are at a much higher risk of experiencing it, close to 1 in 2 such women. But crucially, PPP can occur in people without a previous diagnosis of severe mental illness, usually (but not always) as a first episode of a bipolar or schizoaffective disorder.
Despite its rarity, PPP is considered a psychiatric emergency because of the potential for serious harm to both mother and baby, including, in extreme cases, suicide or infanticide.
PPP can emerge extremely suddenly, sometimes within hours of giving birth, with most cases beginning within the first two weeks. For others, the illness evolves more gradually. Symptoms can include mania, hyperactivity, irritability, severe depression, anxiety, paranoia, and psychotic symptoms like delusions (false, bizarre ideas, usually with persecutory content) and auditory or visual hallucinations (hearing voices or seeing things that are not there), which may centre on the baby. Severe insomnia, disorganised thinking and behaviour markedly different from the person’s usual character are also common.
The clinical picture can also fluctuate considerably from day to day, or even hour to hour. Someone may appear calm and lucid at one point and later experience profound confusion and the aforementioned psychotic symptoms.
This does not mean that a woman has PPP one moment and not the next, rather, the ongoing illness changes its presentation rapidly. Also, these fluctuations do not make these symptoms less real when they occur.
As Professor Carmine Pariante (ITM Editor-in-Chief and a researcher and clinician in perinatal mental health) told me: “Once you see a woman with PPP, you never fail to recognise it again, and when the husband or the family see their loved one experiencing PPP, they always know something is not right.”
Importantly, the features described above detail what can occur, they are not a checklist of what must occur. A person does not need to display every symptom, or display them continuously, for their illness to be severe.
The Clancy Case
Clancy does not deny killing her children. Her defence argues instead that she was not criminally responsible for the deaths of five-year-old Cora, three-year-old Dawson and eight-month-old Callan, because she was experiencing hallucinations and delusions at the time of the killings, because of PPP.
Expert witnesses for the defence, such as forensic psychiatrist Dr Phillip Resnick, testified that Clancy heard a voice telling her “This is your last chance. Kill the children so you can kill yourself,” acting as a direct command, a typical psychotic symptom. After the killings, Clancy jumped from a second-floor window to kill herself, leaving her paralysed from the waist down.
Prior to the killings, Clancy had experienced anxiety, insomnia and depression, received inpatient psychiatric treatment, been prescribed several psychiatric medications, and searched online for terms like “psychosis”.
Clancy’s defence’s central argument is that this “fragmented care” and systemic medical failures were to blame for her catastrophic psychiatric decline. Clancy’s former mother-in-law testified that Clancy was “begging for help” when describing how Clancy’s mental health deteriorated following the birth of her youngest son.
Prosecutors, on the other hand, have argued Clancy deliberately killed her children, sending her husband out for errands so that she could kill them. The prosecution has pointed to evidence they argued demonstrated planning, awareness and purposeful behaviour.
It is tempting to interpret apparently organised or purposeful behaviour as incompatible with psychosis. But, as described above, severe psychiatric illness does not always look the way we expect it to.
So, someone can behave coherently while experiencing psychosis.
Someone can perform organised actions while experiencing psychosis.
Neither observation tells us, on its own, what Clancy's mental state was when she killed her children. Professor Paola Dazzan, an expert in PPP involved in the campaign for the recognition of this as a distinct category, explains: “The crucial issue is whether she killed her children because her false, delusional beliefs, and the voice she heard, led her to do this, rather than how organised or premeditated she was in her actions. While I only know the clinical details that I have seen in the news, the picture I saw described is certainly compatible with PPP”.
What I Hope We Take From This Case
There is no way to write about this case without acknowledging the enormity of what happened. Three young children lost their lives. My heart breaks for them, for their family, and for Lindsay Clancy, who by all accounts was a devoted mother. Whatever conclusions are ultimately reached about her mental state and criminal responsibility, this is an unimaginable tragedy for everyone involved.
But PPP is not synonymous with violence. Most women experiencing severe perinatal mental illness will never harm their children. Yet PPP is a psychiatric emergency, and without timely and adequate care, its consequences can be devastating.
And our words matter. Somewhere, a new mother may be experiencing terrifying thoughts, hearing voices or feeling profoundly confused. If she sees women with psychosis described as monsters or inherently dangerous, she may become more afraid to disclose what she is experiencing.
We can discuss difficult cases while recognising the limits of internet sleuthing. I do not know what Lindsay Clancy’s mental state was when she killed her children. But the plethora of non-expert opinions surrounding this case has exposed how profoundly misunderstood PPP remains.
The lesson should not be that women experiencing PPP are dangerous, but that severe mental illness must be recognised, understood and met with timely and compassionate care.
To access more information and support, Action Against Postpartum Psychosis (APP) offers dedicated resources for women and families.
