Postpartum Depression, Psychosis, and Infanticide

Postpartum mood disorders are more common than is often realized: Up to 80 percent of new mothers experience mild depression within a year of giving birth. If the ‘‘baby blues’’ persist, depression can escalate to dangerous levels, influencing some women to experience psychosis and—in rare and tragic cases—to kill their offspring.

As many as 50 to 80 percent of all women experience some degree of emotional ‘‘letdown’’ following childbirth—the so-called ‘‘baby blues.’’ The ‘‘baby blues’’ is common for numerous reasons. The baby’s crying and the mother’s interrupted sleep and soreness from breast-feeding are enough to make any woman feel irritable, if not overwhelmed and tearful. These feelings typically begin three to four days after the baby is born but normally dissipate on their own within a few weeks. In addition, rapid shifts in reproductive hormone levels, particularly progesterone, may contribute to a vulnerability to more severe depression among some new mothers. Fortunately, its more extreme sister disorder, postpartum psychosis, is rare, affecting only about 1 or 2 in 1,000 new mothers.

Women are more likely to experience psychiatric illness after childbirth than at any other time in their lives. If the ‘‘baby blues’’ last for more than two weeks, however, the new mother may be suffering from a condition of intermediate severity, postpartum depression (PPD), a mood disorder on par with other forms of clinical depression. Ten to 22 percent of women experience PPD before the infant’s first birthday. PPD is characterized by feelings of despondency, inadequacy as a mother, impaired concentration and memory function, as well as loss of interest or pleasure in activities that were formerly enjoyable. In addition, the mother experiences excessive anxiety about the infant’s wellbeing. Mothers with postpartum depression are reluctant to share their upset emotions because they do not want others to think of them as bad mothers.

Some women also become paralyzed with fear and concern for the baby’s safety. If such symptoms appear, it is important to seek professional consultation to help differentiate PPD from other conditions such as obsessive-compulsive disorder. Symptoms of anxiety are frequently an aspect of clinical depression, but true obsessive-compulsive symptoms signify a different disorder that needs proper diagnosis and treatment.

Though debilitating, the depressive emotional reactions that may accompany becoming a new mother are not as severe as those associated with postpartum psychosis. In psychosis, the hallmark symptom is a ‘‘break’’ with reality—a loss of the ability to accurately discern what is real from what is not. For instance, a woman with PPD may experience violent thoughts about her baby but recognizes that those thoughts are wrong and potentially dangerous. In that case, she will not act on them.

However, a woman suffering from a full-fledged postpartum psychosis will have lost, at least temporarily, the judgment needed to make this assessment. Very often, a woman with psychosis experiences a frightening sense of merger with her infant—she cannot differentiate where she ends from where her baby begins. Psychotic merger is so terrifying that she may try to avoid losing her sense of self by either committing suicide or killing the baby or both. Infanticide is the term used to refer to murder in which the killer is a parent of the victim.

In the month directly following childbirth, women are twenty-five more times likely to become psychotic than during other periods of their lives. Postpartum psychosis occurs following only 1–2 per 1,000 births. Furthermore, the risk of infanticide associated with untreated puerperal psychosis (occurring during childbirth or the period immediately following) has been estimated to be as high as 4 percent.

Women with puerperal depressive disorders experience a high relapse rate during subsequent pregnancies: 50 percent or more of women who had a previous episode of postpartum depression experienced a relapse following a subsequent pregnancy. However, for postpartum psychosis, the relapse rate is even higher—it is almost 80 percent.

Filicide and Neonaticide

There are two distinct types of infanticide. Filicide is the killing of a son or daughter older than twenty-four hours. Neonaticide is the killing of a newborn within twenty-four hours of birth. Neonaticide is a separate entity, differing from filicide in the diagnoses, motives, and disposition of the murderer. About 3 percent of all American homicides are filicides. The reported rate of murder for children less than one year of age has remained relatively stable over the past twenty years. The rate of killing children under one year is 4.3 per 100,000 live births.

Estimates of the occurrence of neonaticide in the United States range from 150 to 300 per year. The Uniform Crime Reports for the years between 1976 and 1985 show that on average about 384 filicides of children up to age eighteen were reported each year. Sixty-two percent of all homicides that occurred in children 0 to 5 years in the United States from 1976 through 1998 were committed by parents (U.S. Dept. of Justice 2000). The risk of filicide is greater among younger than older children.

Nevertheless, infanticide is a very rare phenomenon; only about 4 percent of women who become psychotic kill their babies. According to one study, 67 percent of women who kill their children are mentally ill, as opposed to only 6 percent of those who kill their spouses. Perhaps even fewer tragedies would occur, however, if proper education and treatment were more readily available to physicians and the public.

The ages of the filicide victims ranged from a few days old to as old as twenty years. The risk of filicide is greater among younger than older children and is greatest within the first year of a child’s life. Among infants in the first week of life, mothers are almost always the ones who commit the filicide. The most dangerous period for the victims is the first six months of life. This is the time of maternal postpartum psychoses and depressions. The younger the child, the more likely is the suicidal mother to think of the child as a personal possession and feel inseparable from the baby.

Comparing mothers who commit neonaticide with those who commit filicide, only a few of the women who commit neonaticide were psychotic, but psychosis was evident in two-thirds of the maternal filicide group. In one study, serious depression was found in only 3 percent of the maternal neonaticide cases compared with 71 percent of the maternal filicide group. In contrast, suicide attempts accompanied more than one-third of the filicides, but none occurred among the neonaticide cases.

Although infanticide is now considered a crime by national governments all over the world, it has been and is still practiced on every continent and by people on every level of cultural complexity, from hunters and gatherers to highly evolved civilizations. Throughout history, the various motivations for infanticide have included population control, illegitimacy, inability of the mother to care for the child, greed for power or money, superstition, congenital defects, and ritual sacrifice. Researchers who study infanticide distinguish several different groups of parents who murder their offspring. Some kill as a result of psychotic delusions—the dread of parent–child merger or the belief that the child is trying to harm or kill them. Others murder their children out of profound depression and hopelessness. Often they carry strong religious ideas that killing their children will enable them both to enter an afterlife more peaceful than their current life.

Neonaticide

The great majority of neonaticides are committed simply because the child is not wanted due to the stigma of a pregnancy out of wedlock. Consistent with this observation, the most common reason for neonaticide among married women is extramarital paternity. Neonaticide is especially common among teenagers who are overwhelmed by dealing with their unexpected pregnancy.

In most neonaticides, the perpetrators are young women who live with their families but are psychologically isolated. Teenagers who commit neonaticide often lack relationships with open, caring, reliable adults who will recognize that they are pregnant and will initiate a conversation to help them make decisions about pregnancy and plan for its consequences. Many girls feel ashamed of having engaged in sexual relations and are fearful that their pregnancies will disappoint and even humiliate their families, causing the girls to experience shame and emotional paralysis.

Passivity is the most common single personality factor which clearly separates women who commit neonaticide from those who obtain abortions. In contrast to women who seek abortions (recognizing the reality of their pregnancy early and promptly and actively seeking to address the problem of an unwanted pregnancy), women who commit neonaticide often deny that they are pregnant altogether or magically assume that the child will be stillborn.

Neonaticide is not usually a premeditated act; frequently it is committed in the face of intense emotion such as shock, shame, guilt, and fear immediately following the delivery of a live infant. Generally no advance plans are made for either the care or the killing of the infant.

The methods of neonaticide listed in order of greatest frequency are suffocation, strangulation, head trauma, drowning, exposure, and stabbings. Suffocation is probably most frequent because of the need to stifle the baby’s first cry in order to avoid detection. The crime is usually concealed. Following the murder, the body is usually disposed of and the mother denies that it has occurred.

Filicide

In contrast to neonaticide, the motives for filicide, in order of descending frequency, according to Resnick, are:

• ‘‘altruism’’ associated with the mother’s suicide (38 percent)
• acute psychosis (21 percent)
• unwanted child (14 percent)
• fatal maltreatment (12 percent)
• to relieve suffering (11 percent)
• spousal revenge (4 percent)

The ‘‘altruistic’’ filicidal mothers see their children as extensions of themselves and do not want to leave them motherless in an uncaring world as seen through the eyes of their own depression. Varying degrees of pathological identification may exist between mother and child, ranging from the mother projecting her own suffering upon the child to psychotic merger.

The ‘‘altruistic’’ filicide raises particular medical legal issues. In most jurisdictions, the criteria for claiming ‘‘insanity’’ as a legal defense against the crime of murder are predicated upon the McNaughtan Rule: The defendant must prove that she did not appreciate the nature and quality, i.e., the wrongfulness and criminality, of her murderous act at the time that it was committed. Severe depression, even without psychotic features, may distort thinking to such an extent that a mother believes that her children will be better off in heaven with her than motherless in this world. In these cases, it is usually clear that the mother knows the nature and quality of her act and that killing her children is legally wrong. However, the filicidal mother often believes that she is also doing what is morally right by killing her child. When these mothers are brought to trial, jury instructions in different jurisdictions vary widely on the meaning of ‘‘wrongfulness.’’ The defense that the mother, although aware of the legal wrongfulness of her act, was conforming to a higher moral authority when she committed filicide has been acceptable in only a limited number of jurisdictions within the United States.

Acutely psychotic filicidal parents include those who killed under the influence of hallucinations, epilepsy, or delirium. However, this category does not include all psychotic child murderers and is the weakest because it includes cases in which no comprehensible motive could be ascertained. One striking example quoted by Resnick from the historical psychiatric literature is that of an ‘‘epileptic mother (who) placed her baby on the fire and the kettle in the cradle.’’ Presumably she was suffering from a seizure disorder now known as psychomotor epilepsy, or ‘‘Jacksonian’’ seizures. A new mother in a similar neuropsychiatric state observed by the author of this research paper held her newborn infant dangerously at fully extended arms’ length and walked aimlessly around a room with one breast completely bare, oblivious to whether she was holding or dropping the child.

Unwanted child filicide requires no further explanation. Fatal maltreatment filicides are invariably the tragic outcome of child abuse such as ‘‘battered child syndrome.’’ In these situations there was usually no clear homicidal intent and death is the unintended consequence of maltreatment that was intended to stop the child’s ‘‘bad’’ behavior. Indeed, child abuse is the most common cause of filicide in the United States. A variation on this pattern includes child maltreatment with the participation of or coercion by a male partner.

‘‘Spousal revenge’’ filicide is a final category, encompassing parents who murder their offspring in a deliberate attempt to make their spouses suffer. Infidelity, either proved or suspected, is a common precipitant for spousal-revenge filicide.

Paternal filicide is a related phenomena but one that is beyond the scope of this research paper. Suffice it to say that men are far more likely than women to commit familicide, i.e., killing the child’s mother as well as the child, often followed by the father’s suicide. In one study of ten paternal filicides from a psychiatric hospital, more than half of the men attempted suicide after the child murders.

There are also characteristic reactions to the deed of filicide. According to Resnick, after ‘‘altruistic’’ and ‘‘acutely psychotic’’ killings, there is often an immediate relief of tension. Resnick notes that ‘‘this explains the failure of some parents to complete their suicide. Furthermore, after the murder, these parents usually run to seek help and make no effort to conceal their crime.’’ By contrast, parents who commit ‘‘unwanted child’’ and ‘‘fatal maltreatment’’ filicide often go to great lengths to dispose of or conceal incriminating evidence and to deny the crime.

In contrast to filicide, most neonaticidal murders belong to the unwanted-child classification. Furthermore, in the incidence of neonaticide, major mental illness in the mother is infrequent. These women tend to conceal the pregnancy, deliver the baby alone, and dispose of the baby secretly.

Conclusion

In summary, there is a spectrum of puerperal mental illnesses, ranging from ‘‘baby blues’’ (which is probably a normative response to rapid hormonal shifts immediately following delivery) to postpartum depression and psychosis, including the rare and tragic outcome of neonaticide by the mother. An effort has been made in this research paper to further delineate filicide from neonaticide, comparing and contrasting the two phenomena. It goes without saying that the best preventive measures to reduce the frequency of these tragic occurrences would be to increase the availability of educational and mental health services as well as emotional support during pregnancy and the puerperal period and to continue making such services more widely available to parents during at least the early years of childhood.

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