On the morning of June 20, Andrea Yates, a suburban Houston mother, killed her five children, drowning them one by one in the bathtub. "I killed my children," she confessed in a calm voice to the investigating policeman who arrived at her home.
Yates represents nature's aberration as a mother, but also a rather textbook example of postpartum psychosis. Or so it seems from the details provided in the media. Yates allegedly had been contemplating the murders for a few months and said she did it because the children were "damaged."
For years, it seems, Rusty Yates knew his wife was depressed, at times even "unrecognizable" as the Andrea he knew. She became deeply despondent after each child was born, he says, although she made no threats to harm her brood. In 1999, however, after the birth of her fourth child, Andrea Yates attempted suicide twice—first with pills and later by cutting her throat. Yates' symptoms lifted after she was put under medical care and given antidepressants. Soon, Andrea had Mary, the couple's first girl.
A few months later, Andrea Yates' father died, and this sent her deeper into despair, according to her husband. Her darkness must have mutated into psychosis because her doctor gave her Haldol—an antipsychotic that treats symptoms like hallucinations, delusions, paranoia, and deeply confused thinking. For some reason, her doctor discontinued Haldol a week or so before the murders. Was this pivotal in the murders? As an antipsychotic, Haldol may have checked her impulses, or it may have softened the delusional ideas she had about herself and her children.
What is postpartum illness? The American Psychiatric Association, which referees this sort of thing for the profession with its Diagnostic and Statistical Manual, first recognized "post-partum psychosis" in 1968 (code 294.4 Psychosis Associated With Childbirth). The entry was removed shortly thereafter, not because postpartum psychosis wasn't real, but because clinicians disagreed over the proper classification of the condition. Postpartum illnesses returned in the 1994 edition of DSM as variants of depression and psychosis, not as a unique diagnosis.
Our culture uses the terms "postpartum depression," "postpartum illness," and "postpartum psychosis" interchangeably to describe the so-called baby blues—a transitory period of sadness, irritability, and anxiety that arrives within a week of childbirth. It affects over half of all new mothers in some form. According to the literature, about 10 percent to 15 percent of mothers suffer more substantial depression, marked by a sense of hopelessness, diminished interest, and an inability to experience pleasure. Those women have trouble concentrating and sleeping, lose interest in food, and occasionally contemplate suicide. They might imagine harming their babies or feel guilty about being bad or undeserving mothers. The feelings start within a month of delivery and can last months, even a year. Before the advent of psychiatric medications, a handful of mothers remained ill for years, according to medical reports from the first half of the century.
Only about one in 1,000 postpartum cases progresses to the point of severe depression (immobilization, intense suicidal preoccupations) or develops a psychotic dimension to the depression, as seems to have been the case with Yates. A tiny fraction of all women giving birth—maybe 0.1 percent—become psychotic without first experiencing depression. When psychotic, the mother may think her baby is evil, that he must be destroyed to save humanity, or she may "hear" God telling her to kill him. Or she may think she's saving the baby by sending him from this hell-on-earth to heaven. Yates told police her children were "damaged," but it's likely that more florid delusions beset her.
The average mother is not at risk for severe postpartum illness. Most vulnerable are those who have endured episodes of significant depression or are bipolar (manic-depressive) and have already experienced depression or psychosis following childbirth. Yates' history of depressions put her at very high risk with this latest baby.
Postpartum psychosis was first used as an insanity defense in an American courtroom in the 1980s, though doctors have recognized it for thousands of years. Around 500 B.C., Hippocrates described the emotional turmoil of women in the third book of his treatise Epidemics, calling it "puerperal fever" (the puerperium referring to the period surrounding birth), and theorized that suppressed vaginal discharge in the days following birth were transported to the brain where they incited "agitation, delirium and attacks of mania." The 11th-century gynecologist Trotula of Salerno speculated "if the womb is too moist, the brain is filled with water," and this manifests as depression. The British medical journal the Lancet describes a case of postpartum psychosis in an 1846 article:
For eight long months the patient was almost constantly excited by night and by day, talking incessantly, often swearing, untiringly active, running about the wards ... and riding the rocking horses like one possessed ... [o]ften mistaking persons and becoming very violent. She unfortunately began to mistake Mrs. Bowden for someone of whom she was jealous and made some rather desperate attacks on her.
The condition's neurobiology has not been defined, but modern researchers widely presume that hormonal shifts initiate, if not sustain, the disease process. In the 1960s, researchers treated women with long-acting estrogen immediately after delivery and were able to suppress most symptoms of "maternity" blues. Abnormalities in thyroid and pituitary function have also been implicated. Today, SSRI (selective serotonin reuptake inhibitor) antidepressants such as Prozac and Paxil are the most common treatment.
Not surprisingly, psychological factors help determine vulnerability. Mothers who didn't want to get pregnant experience greater risk for milder forms of postpartum illness than those who wanted their babies. The birth of a premature infant or difficult labor also enhances risk, as does a mother's feeling that she is not getting adequate emotional and material support. Mothers report the baby blues more often in the United States than in other countries, but the condition cuts across cultures.
Edward H. Hagen, an anthropologist at the University of California at Santa Barbara, offers a sociobiological theory of postpartum depression. He argues that diminished maternal investment in the offspring could be adaptive under conditions of insufficient intimacy and resources. Writes Hagen, "Because human infants require enormous amounts of investment, ancestral mothers needed to carefully assess both the availability of support from the father and family members and infant viability before committing to several years of nursing and childcare."
What distinguishes the baby blues from something more malignant? Families should be on the lookout for distress that doesn't disappear after a week or so, as well as symptoms that interfere with caretaking, such as sluggishness, sadness, uncontrollable crying, hopelessness, a sense of doom, poor concentration, confusion, and memory loss. Other markers include obsessive checking on the infant or an irrational fear on the mother's part that she might harm the baby or herself.
We should, however, resist the modern tendency to label all emotional discomfort—shyness in adults, for example—as sicknesses requiring medication. Postpartum doldrums are natural, whether their underlying causes be hormonal or psychological. For most mothers most of the time, the best remedies are helpful mates, supportive families and friends, and time.