E187 | Can Psychiatrists Predict the Unthinkable? | The Lindsay Clancy Case

The Lindsay Clancy case has prompted an enormous debate about postpartum psychosis, criminal responsibility, psychiatric treatment and whether severe mental illness can ever be reliably predicted.

In this episode Dr. Alex examines the case not to deliver a verdict on Lindsay Clancy, but to explore what it reveals about the realities and limitations of psychiatry.

The episode looks at Lindsay Clancy’s psychiatric deterioration after the birth of her third child, her treatment for anxiety, depression and insomnia, her admission to McLean Hospital, the unusually complicated sequence of psychiatric medications she was prescribed, and the competing claims surrounding the case.

It also explores some of the most difficult questions in mental healthcare: How accurately can psychiatrists predict suicide or violence? Can someone appear organised while experiencing psychosis? How difficult can postpartum psychosis be to detect? Can starting and stopping psychiatric medications destabilise someone’s mental state? 

Presented by Dr. Alex Curmi. Dr. Alex is a consultant psychiatrist and a UKCP registered psychotherapist. Website: alexcurmitherapy.com

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Alex is not currently taking on new psychotherapy clients, if you are interested in working with Alex for psychological coaching , you can email - alexcurmitherapy@gmail.com with "Coaching" in the subject line.

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Transcript

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We're going to be talking about the Lindsay Clancy case. As with everything nowadays, any major news event is immediately absorbed into the culture war. Almost no one is in a position to have a strong opinion on this case. In psychiatry, when it comes to these low probability events like suicide and homicide, you really are looking for a needle in a haystack. In psychiatry, we're forced to make difficult decisions based on incomplete information. I think as a culture, one thing that would be really good to do is to stop looking at cases like this and think, oh, this really deserves our input and our hot take. Welcome back everyone. It's been a while since I've been able to release an episode. I didn't plan on this, but there was a couple of weeks where I wasn't able to release an episode. Apologies for that. There's a lot of stuff going on behind the scenes here at the Thinking Mind, but I promise you, we're working every day to try and get you the best content about mental health possible. Today we're going to be talking about something very serious and very tragic. We're going to be talking about the Lindsay Clancy case. Of course, a lot of people are talking about this. There's a lot of stuff in the media, there's a ton of stuff online. For those who don't know, this is the case of a 36-year-old woman recently on trial for taking the lives of her three children, where the defense are claiming that the defendant is not guilty by way of insanity, and they're talking about things like bipolar and postpartum psychosis. This has spent a huge conversation online, and I think there's a lot that can be learned from this case about psychiatry, how psychiatry works, what it does well, and what it does badly, mental health. I also think this case is a huge litmus test for where we are as a culture. So we're going to be talking about all that today. For those of you who don't know me, my name's Alex. I'm a consultant psychiatrist and psychotherapist, and I work with people for psychological coaching when they're stuck in life. I'll say from now, this episode is not going to be an attempt to cast a verdict on Lindsay Clancy or even on the quality of care that she received necessarily, although we will be talking about it. That's not really what this show is about. And also we're not going to be casting verdicts today because here's my first take: almost no one is in a position to have a strong opinion on this case. Maybe if you're an experienced perinatal psychiatrist, maybe if you've had personal experience of something like postpartum psychosis, but many many people feel very comfortable having a very strong opinion on this case, a very certain opinion, even though they have little or no experience with these kinds of postpartum mental health issues. I saw it when I was discussing the new Channel 4 documentary about ADHD, the great ADHD myth, where you can see people who have little or no experience of dealing with, working with, or living with ADHD are very comfortable having very, very strong opinions. And the the reputation of expertise certainly has fallen off a lot in recent years, and there are very good reasons for that, but we still need expertise. Expertise and experience is very important. Even though I'm a general adult psychiatrist, I think as I'm qualified to talk about the different lessons maybe we could learn from this, but even I don't think I'm qualified to have a really strong opinion on the specific case and the outcomes. So we're going to be talking about what we can learn from this case today. Let's just recap briefly what happened for those who aren't aware. We're dealing with 36-year-old Lindsay Clancy. In May 2022, she gives birth to her third child, Callan. She was previously working as a labor and delivery nurse and she doesn't return to her job. In September 2022, she begins seeking psychiatric treatment and she's dealing with anxiety, low mood, difficulty coping. She starts an antidepressant at that time. Between October and December 2022, her symptoms worsen, her treatment becomes more complicated, she's prescribed many different drugs, and we'll talk about the drugs a bit later in the episode. In total, she's prescribed something like 13 different medications. Not that she's taking all of them at once, but 13 different medications over a period of time. In December 2022, concerns increase about insomnia, anxiety, the possibility of suicidal thoughts, the possibility of maybe a bipolar type illness, mania, depression. Family members have testified during this time she's increasingly not like herself. On January 1st, 2023, she's admitted to hospital. And my understanding this is because of suicidal thoughts. So she's admitted to McLean Hospital for psychiatric treatment. She's discharged five days later on January 5th. On January 23rd, she has an online psychiatric appointment. During this appointment, she reports being depressed, but she does not report hallucinations. She does not report thoughts to harm herself or harm others. The next day, on January 24th, 2023, she apparently has a normal start of the day. She takes her daughter to a medical appointment, spends time with her children playing. Later, while her husband Patrick is out collecting food and medication, she takes the life of her three children, and then she jumps from an upstairs window in an apparent suicide attempt, and this causes a severe spinal injury. And as a result of that, she's paralyzed. She's still paralyzed now. The trial, as you guys probably know, took place this summer and it just ended a few days ago. Most of the jury, it appears, thought she would be not guilty by reason of insanity, and one jury member didn't agree with that. So there's a hung jury and a mistrial. So I guess the first thing to say is what a crazy response there's been to this online, where as with everything nowadays, any sort of major news event is immediately absorbed into the culture war. So aside from talking about psychiatry and mental health, and I think it's good that people are having conversations about this because of this case. People are now talking about motherhood, gender, accountability, feminism. There's discussion online as to how supporting or not supporting Lindsay in this particular case is an important sign of your character. People are taking very extreme, rigid views about it. Again, even though they don't know the person involved, they don't know the psychiatric team involved, they don't know what happened with her care. People are very willing to take a very hard view. And I think it's because this case is so it's it's so tragic, but also it's so archetypal and it taps into our deepest fears and our deepest anxieties. A lot of women have really spoken out in support of Lindsay Clancy, and I think I understand why this is. These women have been criticized by a lot of people on the far right, that somehow women supporting Lindsay Clancy is a sign of the excesses of feminism, which doesn't make sense to me. I think conservative commentators like Matt Walsh talk a lot about this. Matt Walsh, incidentally, doesn't seem to believe that you that someone can be not guilty by reason of insanity at all. He doesn't really believe in that as a defense. And that to me again shows that he has no experience of dealing with mental illness. I think one important reason why so many women support Lindsay Clancy is because having very difficult and dark thoughts during early motherhood in particular is way more common than people would like to think. And I know it's taboo, and I know if you've had those thoughts, you probably don't want to talk about it. And that's okay because I can talk about it. I have obviously worked a lot clinically with people who have mental health difficulties, and I can tell you, parents in general, but particularly mums, and particularly mums in the early stages of motherhood, the stress, the sleep deprivation, often the isolation makes it very, very common for mums to have very dark thoughts in general, dark thoughts about themselves, self-criticism, guilt, and even dark thoughts about their child. Sometimes thoughts about hurting their child. Thankfully, most of the time, these thoughts never result in any kind of action or damaging behavior, but in rare cases, like the Lindsay Clancy case, they do. And so I think a lot of women look at the Lindsay Clancy case and they say, if the circumstances were a bit different, they could have been in that situation. It does happen, and we're we're all capable of falling into a deep state of mental illness. It's a good thing that most of us don't, but it could happen to any of us with the wrong, you know, genetic predisposition, the wrong amount of stress, the wrong circumstances. This could happen to any of us. Fortunately, it doesn't most of the time. And so I think that's why a lot of women can relate to her position. I think this case says a lot about some of the difficulties with psychiatry, both the problems with how services are set up, which I'll talk about a bit later, but also just the problem of being a psychiatrist. It's actually very difficult, can be a very difficult job to do well, especially when you're dealing with these uh more extreme situations and presentations. So what's clear in this case is what we could call the hindsight problem of psychiatry, which obviously we know this idea hindsight is 2020. It's much easier to look at a case when you know that the bad thing has happened and look at the warning signs and say, hey, there was this warning sign, there was that warning sign. So in the trial, you have, you know, Lindsay's relative saying, Oh, I was worried that she wasn't like herself, I was worried about paranoia. You can forensically analyze each of the appointments that she's had. The truth is in psychiatry, when it comes to these low probability events like suicide and homicide, you really are looking for a needle in a haystack. They're rare. For the amount of people that psychiatrists see where they're complaining of suicidal ideation, actual completed suicide is really rare. So you might look at a case, for example, where someone has taken their own life, and you might look at an appointment and see they were talking about having suicidal thoughts, and you can say, hey, that psychiatrist should have picked that up because they were talking about suicidal thoughts. But what you're not seeing is all the appointments that psychiatrist is having where they're seeing patients who are complaining of suicidal thoughts, but it never actually translates into the behavior, it never translates into actual self-harm or suicidal action. So you're looking for a needle in a haystack, and with this case, as with any case, you can find all the warning signs along the way, but it's very difficult to do that prospectively. Obviously, as a psychiatrist, you're always doing your best to risk-assess people and try and make the best decisions possible, but it can be very difficult, and cases do get missed. Again, to be clear, I am not trying to prosecute the people involved in hair care, nor am I particularly trying to defend them. I'm just trying to talk about the problems with dealing with mental health issues. If you like this video so far, do like, comment, or subscribe ideally on YouTube, or wherever you happen to be listening or watching, that's the best way to support us. The other thing is, as we talk about a lot on this podcast, psychiatric diagnosis is very tricky. It's often provisional. Symptoms often evolve slowly over time. So you might think, okay, this person is primarily suffering from depression, and then new symptoms might emerge, which might make you think, oh, this might actually be bipolar disorder, a combination of depression, and then later a manic episode, which is kind of the opposite of depression, or they may develop hallucinations, which might also complicate the diagnostic picture. Often in psychiatry, and this seems to be the case in this case, there are a few unusual things about it, which I'll talk about. But the picture is clearly evolving and dynamic, it's not one static set of issues that Lindsay was presenting with. And this brings us on to postpartum psychosis in general. So, for those of you who don't know, the postpartum period is generally thought to be the first year or so after childbirth, and it's a vulnerable time for developing a mental health condition. Often, for example, women who end up having bipolar have their first manic episode, often in that first year postpartum. Sometimes people have psychotic episodes postpartum and they resolve and they never have psychosis again. But it's generally considered to be a very vulnerable time, and the main reasons for that are likely to be the hormonal shifts. So in the postpartum period, you have major hormonal shifts, and which can make someone vulnerable to a mental illness. You have the sleep deprivation and you have the stress. So you can imagine if someone has any kind of genetic predisposition to having a mental health condition like psychosis, and maybe mental health symptoms have never manifested before, but then they give birth and they're postpartum, and they have this combination of stress, sleep deprivation, and hormonal shifts, and something could emerge for the first time. And possibly this is what happened in Lindsay's case. Postpartum psychosis in particular, not we know, you know, it's very common to have the baby blues, that's usually the first couple of weeks after giving birth. Then you've got postpartum depression, and then you've got postpartum psychosis specifically. So by psychosis, I will mean hallucinations, which are usually auditory, you know, hearing voices, for example, but they could be visual uh as well. Uh often some kind of delusional belief. So in the case of postpartum psychosis, often it's the belief that something is inherently wrong with the mom. The mom thinks there's something wrong with them, something broken about them, something wrong with their children. This is something we're trained on. So, as psychiatrists, we're trained to ask mothers a lot about are you experiencing any kind of unusual beliefs right now? Are you hearing voices? Especially if you see a mom who's already depressed postpartum, you're trained to try and pick up on these delusional beliefs, on these hallucinations. And I think postpartum psychosis is often quite different to more traditional psychosis in that the symptoms are often harder to elicit from the patient. It's often harder to get the patient to talk about them. And I don't know if there's more of a literature on this, but the way we were trained was to assume that it can be quite difficult to actually get the patient to talk about this stuff. The mum might talk about feeling down and she might be experiencing all sorts of unusual beliefs and hallucinations, but she might not talk about them unless you gently and carefully pull on the thread of the conversation, and then she might say, Oh, actually, you know, I am believing, for example, that there's something wrong with me or something wrong with my kids. But the way we're trained in psychiatry is to assume these things are quite difficult to elicit and to very gently um ask the mom to try and build up the picture slowly. And in the Lindsay Clancy case, what she testified is that on the morning where everything happened, she began to experience a command hallucination. So there's lots of different kinds of hallucinations. Sometimes people hear voices talking about the person, those are called like third-person hallucinations. Sometimes people experience a command hallucination, a voice telling them to do something. In psychiatry, we're trained to take command hallucinations quite seriously, in that often people do actually carry out those commands. And so Lindsay testified that she heard a command hallucination over and over again, telling her that the only way to save herself and her children was to take her children's life and to take her own life. It's not clear to me how much these symptoms were inquired about or asked about in the appointment she had the day before. Um, and that's why it's I'm I'm hesitant to pass any kind of judgment on the psychiatrist at this time. Now, postpartum psychosis is rare enough so that most people don't really have it much experience with it. Again, especially if you're not a perinatal psychiatrist, but it's common enough that it should be taken really seriously. So postpartum psychosis occurs in one to two cases for every live 1,000 births. And what that translates to is something like 20 women a day in the US experiencing something like postpartum psychosis. So, again, pretty rare through one way of looking at it, but happening often enough that we need to take it pretty seriously as an issue. And I think one of the good things about this case, tragic although it is, is that at least people are having more of a conversation and developing more of awareness of how difficult and stressful the postpartum period can be for women. A few things worth mentioning about this case. Prior to this few months, she has no history of mental illness, she has no history of violence, she has no history of aggression, and in terms of her character, everyone around her testifies that she was a loving mum, a devoted nurse. Again, she worked as a labor and delivery nurse, and I think that's important to mention. She had no history of psychosis, she had no history of manic episodes. It is a little bit unusual that all of this stuff occurred relatively late postpartum, it's about eight months in, and normally postpartum psychosis um occurs in the first few days or weeks, but eight months is still very much considered within the postpartum period. And again, maybe eight months means there's less of the huge hormonal shifts, but there's still a ton of the sleep deprivation and the stress. And she was looking after three children uh at the time, as I said earlier. Uh, other interesting things about this case, so she was on a lot of different medications during this time. So she was on 13 different medications. I actually have a list here, so she was on serculin and SSRI antidepressant, lorazpam, which is a benzodiazepine, she was on a sedating antihistamine to try and get to sleep, pusperone, a medication to reduce anxiety, trazodone, another antidepressant, fluoxetine, another SSRI antidepressant. She was on zolpidem, a hypnotic to help with sleep, mytazepine, another antidepressant, clonazepam, another benzodiazepine, quitiapine, uh, an atypical antipsychotic, diazepam, another benzodiazepine, lamotogen, a mood stabilizer, and amitriptin, another antidepressant. So I can't I don't have the exact timeline of what medication she was on when, but she was on all these different medications throughout a few months, period. Now, I think one thing we are starting to recognize in psychiatry more and more is the effect of starting a medication, increasing the dose, decreasing the dose, stopping a medication, switching to another medication, that that in itself it can produce withdrawal effects, which can be very mentally destabilizing, and that all this starting, stopping, and switching can destabilize someone's mental state. And I think in rare cases, can increase the likelihood of something like a psychosis or a manic episode or a combination of both. I can't say definitively that this was the case in this situation, but I think it's something important that needs to be taken into account, and I think psychiatry needs to start grappling with this more, that starting and stopping medications frequently itself potentially can be a destabilizing factor. Something I've noticed in my career as a psychiatrist is that often as a doctor, you can be very compelled to start a medication or switch to a different medication if things aren't right yet. As doctors, we feel compelled that we need to do something, we need to act. And often the act is increasing the dose of a medication, switching a medication, starting something. And I think we need to re-examine this a little bit because sometimes the right thing to do is to do nothing, to watch to wait on a particular dose of a medication, make sure the person has enough supervision, make sure they have enough support in lots of different ways, make sure they're doing non-medication things they need to be doing. Uh, but sometimes with the medication itself, I do think the right thing to do is to watch and wait. Sometimes the right thing to do is to maybe lower the dose of the medication, sometimes the right thing to do is to do nothing medication-wise. And the sense that you get uh with this case is that the prescribers were very much wanting to try and change and improve Lindsay's mental state as fast as possible using medications, but by doing so, potentially it may have increased the risk of her mental state actually destabilizing. I don't think yet we fully really understand the effect of starting and stopping so many different medications in such a short space of time. So for the psychiatric trainees and future prescribers listening, this is something I think we want to be more aware of. Sometimes the right thing to do is to do less, not necessarily do more. So I think that's an important aspect of this case. Again, I'm not saying definitively this was responsible for what happened, but could it have been a contributing factor? Absolutely. The other thing you realize when you look at this case is that Lindsay was dealing with so many different services. She had her primary psychiatrist, she was seeing as an outpatient in the community, there was a crisis line, a suicide hotline, there was a weekend crisis service, there was the hospital where she was admitted as an inpatient for five days. And again, every time she attended a different service, her medication was all. In some way, it appeared, and it also seems like these different services weren't very good at talking to each other, coming up with a consensus. And that's a huge problem. It happens in the UK, it doesn't happen all the time in the UK. It depends on the person's specific situation and where they are in the country. But it's especially likely to happen if for some reason someone moves quickly or changes their location, or maybe they live somewhere but they attend AE out of area. And so it's something we want to be aware of as much as possible. We want to improve the communication between different services: AE, outpatients, inpatients. It's very important because otherwise, you have each doctor working with their own theory of what's going on in a situation that's evolving very rapidly. And the other thing I did want to mention about postpartum psychosis is one thing that makes it different from more typical psychosis like schizophrenia and someone who isn't postpartum is that the symptoms can change very rapidly. Someone can be fine, you know, one day and then very much have severe symptoms the next day, which is, it appears, what happened in this case. And so, even more, you want to make sure different services are talking to each other and coming up with more of a consensus. So I think this is something we need to take into account again in the future of psychiatry as how we design services and making sure there's better communication. A lot of times people feel, well, if you can just admit them to hospital, if you can admit a person in crisis to hospital that can solve all problems. And again, this is a case which really shows that isn't the case because Lindsay ultimately was admitted for a five-day admission, a voluntary admission, when things were getting difficult and she was complaining of suicidal thoughts. As far as I can tell during this admission, she wasn't talking about hallucinations or anything like that. And ultimately, it seemed like she was well enough to go home. Again, this speaks to the hindsight problem of psychiatry. It's very difficult in a condition which can change very rapidly, where medications are being started and stopped very rapidly. It's very difficult to know what to do. In psychiatry, we're forced to make difficult decisions based on probability and based on incomplete information. So admitting that someone to hospital, unfortunately, doesn't entirely remove uncertainty and it doesn't eliminate the possibility of a bad outcome, especially when symptoms continue to be present and you haven't definitively started to treat them yet. Other things people have talked about in relation to this case, that, for example, because she was able to still behave in a planned and coordinated way, that she wasn't psychotic, and that's definitely not true, in that people with psychosis, sometimes the psychosis is so severe that they the patient can't even formulate a sentence and they can't behave in any kind of planned way. But plenty of people are psychotic and they are very much able to coordinate plans, they are still able to do um step-by-step actions and work towards a goal. The issue is that when someone has psychosis, their goals are often influenced by delusional beliefs that they wouldn't have if they weren't psychotic. So, for example, someone might believe when they're psychotic that there's like an implant in their tooth tracking them by the government or something like that. And as a result of that belief, they may pull their tooth out. Now, can you say that someone was really, you know, responsible for making that decision lucidly? I would say no, because they are psychotic. Again, if you haven't had experience with psychosis, you must understand that it is a condition where where it's severe enough, which happens often enough, people are not in contact with reality. They are not acting on sound beliefs. And that is why we have this defense. We have this defense by reason of insanity. There's a good reason why it exists. So, again, when conservative commentators like Matt Walsh say we shouldn't even have this, I don't I don't understand how you could reach that conclusion unless you have no experience dealing with mental illness or psychosis. The other thing to say, of course, is just because you have a mental health condition, it doesn't mean that you're not responsible for your actions should you commit a crime. It's very possible that you can do something while having something like schizophrenia or bipolar disorder, and you can still be held criminally responsible for your actions. It depends on what the action was, it depends on what your mental state was at the time that you took it and what were your beliefs, what were your motivations at the time, were they influenced by delusions? Were they influenced by hallucinations, stuff like that? In the case of the Lindsay Clancy trial, it's very difficult to understand what her motivations or her beliefs or her goals were, besides the possibility of being influenced by a severe postpartum psychosis. Now you could say, oh well, that maybe she was a psychopath, because we know you know some people are psychopathic, very different from psychosis, and they kill people because they're sadistic or for other more complex psychological reasons and not because they're under the influence of delusions or hallucinations. That's fine, except Lindsay has no history of this kind of behavior or these kinds of personality traits or these kinds of actions. She has no history of like sadistic behaviors or aggression or violence or anything even resembling psycho psychopathy. And again, she was held in high esteem by everyone around her before any of this. So it's very difficult to understand why she would have done anything like this were it not for the influence of a postpartum psychosis. And I would say that's probably likely why ultimately the majority of the jury so far has voted not guilty by reason of insanity, although, as I said, it is now a hung jury and it is considered a mistrial. It remains to see what's going to happen next. As I said, I think it's very easy to look at a case like this and project all of your own beliefs and predispositions and your own political beliefs or your beliefs about gender dynamics onto this case. And I think as a culture, one thing that would be really good to do is to stop looking at cases like this and think, oh, this really deserves our input and our hot take. And I think what we need to do is learn, we need to learn because ultimately this case is tragic. The best thing we can do when something like this happens is try to learn as much as possible as individuals to decrease the chances of something like this happening again. And one good thing that's happened that's come out of this tragic case is I do think it makes it less likely, you know, if you learn about this case, if you learn about postpartum psychosis and how difficult that post-childbirth period is, you know, it makes it much more likely that you're going to be a better husband, wife, brother, sister, family member, and that you're gonna be more able to support someone when they're going through something like this and hopefully prevent something like this happening in the future. So that's my thoughts on the case so far. I hope you found this useful. If you like this podcast, the best way to support it is to like, leave a comment, subscribe, ideally on YouTube. But wherever you happen to listen, if you listen on Apple, Spotify, you can leave us feedback. Again, the best place to do that is in the YouTube comments. That's where I'm directing all the feedback to every episode we make. So that makes it more likely I can answer each and every piece of feedback. Feel free to leave a comment on the video. If you're interested in my coaching service, if you're feeling stuck in a particular point in your life, that could be career relationships, self sabotage. There's a link to how you can do that in the description. In the meantime, thanks so much for watching, and I'll see you next time.