In January 2023, Lindsay Clancy, a labor and delivery nurse in Duxbury, Massachusetts, was accused of killing her three young children before attempting to end her own life. The case drew national attention, and in the weeks that followed, "postpartum psychosis" went from a term most people had never heard to one they were searching for at two in the morning.
This article is not about the case. We were not involved in her care and cannot offer an opinion on her diagnosis, her treatment or the legal questions that followed, and it would be irresponsible to try. What we can do is answer the questions the case raised for a great many new parents and their families: What is postpartum psychosis? How is it different from postpartum depression? Is the frightening thought I had about my baby a sign of it? And what should I do if I am worried about someone I love?
If you are a new parent and reading this because you are frightened by your own thoughts, please keep reading. The most common reason for that fear is not psychosis, and it is treatable.
If someone is in immediate danger, call 911. For a mental health crisis, call or text 988. Postpartum Support International runs a helpline at 1-800-944-4773 (call or text) for parents and families.
What postpartum psychosis is
Postpartum psychosis is a rare, severe psychiatric illness that begins in the days or weeks after childbirth. It affects roughly one to two in every thousand deliveries. Its defining feature is a break from reality: the person develops beliefs that are not true and cannot be reasoned away (delusions), or perceives things that are not there (hallucinations), often alongside confusion, severe agitation, rapid mood swings and an inability to sleep even when the baby is sleeping.
Onset is usually fast, typically within the first two weeks after delivery, and the picture can change hour to hour. A woman may seem lucid in the morning and profoundly confused by evening. Family members often describe it as "she is not herself" or "it is like talking to a stranger."
The strongest known risk factor is a personal or family history of bipolar disorder or a previous episode of postpartum psychosis. Many women who develop it, however, have no prior psychiatric history at all, which is part of why it can go unrecognized until it is severe.
Postpartum psychosis is a psychiatric emergency. It carries a real risk of suicide and, far more rarely, of harm to the infant, and those risks are driven by the psychosis itself: a mother acting on a delusion she believes completely. It almost always requires hospitalization, and with treatment, most women recover fully.
How it differs from postpartum depression
Postpartum depression is far more common. The CDC estimates about one in eight women who recently gave birth experience its symptoms. It looks like depression at any other time — persistent low mood, loss of interest, guilt, exhaustion beyond what a newborn explains, difficulty bonding, hopelessness — with onset anywhere from the first weeks to the first year. We have written about it in detail in our guide to postpartum depression symptoms and treatment, and it is a central focus of our women's mental health care.
The key differences:
- Reality testing. A woman with postpartum depression knows what is real. She may feel worthless or believe she is a bad mother, but she does not hold fixed false beliefs about the world. In psychosis, that line is lost.
- Speed and severity. Depression usually builds over weeks. Psychosis often erupts over days, and the person's state fluctuates dramatically.
- Sleep. New mothers with depression are exhausted and want to sleep. In psychosis, a woman may go days with almost no sleep and not feel tired.
- Insight. Women with postpartum depression frequently know something is wrong and feel ashamed of it. In psychosis, insight is often absent; the person may not believe anything is wrong at all, which is why families, not patients, usually make the call for help.
Postpartum depression can be serious, and severe depression can include suicidal thoughts that also need urgent care. But it is a different illness with a different course and, usually, outpatient treatment.
Intrusive thoughts are not psychosis
This is the part of the article we most want new parents to read.
A large majority of new mothers, and many fathers, experience unwanted, intrusive thoughts or images of harm coming to their baby: dropping the baby on the stairs, the baby drowning in the bath, a sudden vivid image of hurting the child. These thoughts are common, they are distressing precisely because they are so at odds with what the parent wants, and on their own they are not a sign of psychosis. They can occur with postpartum anxiety, postpartum depression or perinatal OCD, and sometimes with no diagnosable condition at all.
Features that typically distinguish them from psychosis include:
- The thought feels alien and horrifying. The parent does not want it, does not believe it, and is often terrified by it.
- The parent takes steps to avoid it: refusing to bathe the baby alone, hiding the kitchen knives, not standing near windows, asking a partner to check on them constantly.
- Reality testing is intact. The parent knows the thought is "just a thought" even while fearing what it means about them.
When these thoughts become frequent, consume hours of the day, and drive avoidance and checking, they often reflect perinatal obsessive-compulsive disorder, though the same thoughts appear in postpartum depression and anxiety, and only an evaluation can sort out which. Unwanted intrusive thoughts do not automatically mean someone intends to act on them, and perinatal OCD in particular is not associated with acting on them. But no single feature — including how distressing the thought feels — is a guarantee, which is why a clinician should assess the whole picture: mood, sleep, substance use, insight and any thoughts of self-harm. These conditions respond well to treatment, typically cognitive-behavioral therapy and, where appropriate, medication that is compatible with breastfeeding. We cover the broader pattern in our article on health anxiety and OCD.
The tragedy of cases like the Clancy case reaching the news is that they can convince a mother with intrusive thoughts that she is dangerous, and drive her further from care. If you are that mother: being frightened by a thought is not the same as wanting to act on it, and the way to find out what is actually going on is to tell a clinician, not to carry it alone. These are among the most treatable problems we see.
Warning signs families should know
Because insight is often lost in postpartum psychosis, partners, parents and friends are the people most likely to recognize it. Seek emergency evaluation the same day if a new mother:
- Expresses beliefs that are clearly untrue and cannot be talked out of them: that the baby is possessed, that someone is coming to take the children, that she has a special mission, that she or the baby is already dead.
- Reports hearing voices or seeing things others do not.
- Is severely confused, disoriented, or seems to drift in and out of awareness of where she is.
- Has gone two or more nights with little or no sleep and does not seem to need it.
- Swings rapidly between elation, agitation, and despair.
- Talks about the baby or the family being "better off" without her, or about ending her life or the children's.
- Seems suddenly, strikingly "not herself" in a way that family cannot explain.
Any one of these is enough. Suspected postpartum psychosis warrants immediate emergency evaluation — call 911 or go to the emergency room — even if she has said nothing about harming herself or the baby, and she should not be left alone with the baby until she has been evaluated. Do not wait to see whether more symptoms appear. That is not an accusation; it is the same precaution you would take for any acute medical illness that affects judgment.
What treatment looks like
Postpartum psychosis is almost always treated in hospital, at least initially, for safety and because the illness changes quickly. Treatment usually involves antipsychotic medication, often a mood stabilizer given the strong link to bipolar disorder, and aggressive protection of sleep. Electroconvulsive therapy is sometimes used and is highly effective when symptoms are severe or not responding. Most women improve substantially within weeks and recover fully over months.
Because the risk of recurrence in a future pregnancy is significant, women who have had an episode benefit from psychiatric planning before and during any subsequent pregnancy. This is a routine part of women's mental health care and is one of the clearest examples in psychiatry of prevention working.
For postpartum depression and perinatal OCD, care is usually outpatient: therapy, medication where indicated, and practical support around sleep and workload. Telehealth has made this dramatically more accessible for new parents, who rarely have the freedom to sit in a waiting room. Our depression and mood page describes how evaluation works, and what to expect at a first visit walks through the process.
If you are worried tonight
- About yourself, because of intrusive thoughts that frighten you: unwanted thoughts like these are common with postpartum anxiety, depression and OCD and do not by themselves mean you intend to act. They still deserve an evaluation. Tell your OB, your primary care doctor or a psychiatrist this week; if the thoughts are unbearable tonight, or you have any thought of acting on them or of harming yourself, call 988 or go to the emergency room. You will not be judged.
- About yourself, because things do not feel real, or you are not sure what is true: tell someone you trust right now and ask them to stay with you and get you to an emergency room today.
- About someone else: trust the "she is not herself" instinct. If you suspect psychosis, go to the emergency room or call 911 now, whether or not she has mentioned harm, and do not leave her alone with the baby.
Postpartum psychosis is rare, and it is treatable. The women who develop it are not monsters; they are ill, and most recover to raise their children. The way to honor the families devastated by cases like this one is to make sure the next mother is recognized in time.