A trainee psychiatrist is awed as a simple medication changes near-catastrophe into full recovery.
by JP Sutherland
Seen from a distance they made an idyllic picture. Rosa was twenty-six, and although the bloom of pregnancy had faded it was being replaced by the deep contentment of first-time motherhood. In her arms was Patrick Junior, ten days old, and gazing steadily into his mother’s eyes. His hand had escaped from his blanket and I marveled, as I always do, at the tiny perfection of an infant’s fingers.
However.
The first sign of something wrong with this picture was the setting. This was the emergency room, and I was the psychiatric resident on-call, so something obviously wasn’t right. And when Rosa started to speak the whole image of contented motherhood gradually crumbled.
“Congratulations on a healthy baby.” I had started conventionally.
“Thank you. Isn’t he wonderful?” She beamed. “And he means an end to infertility.”
“Your doctor’s referral letter said that you’d had some difficulty conceiving. Tell me more about that.” The referral note had gone a lot further, but I wanted to hear it for myself.
“Well, Patrick cured my infertility, and now he can cure others.”
“I understand about him being an end to the struggles you’ve had, but explain to me how he can cure others.”
“I just have to give them a part of him and then they’ll be able to conceive.”
“A part of him…?”
“Yes. The fingers I think.” She frowned. “I don’t like to think of having to cut them off, they’re so perfect.”
“But you wouldn’t actually do that would you?”
She looked at me with a disquieting intensity. “I have to. You don’t understand. But it would be terrible as well, I know that.”
I paused, not for any purpose or effect, but because for once I was truly speechless and had to think. But she broke the silence before I did, with a return of her smile after the moment of doubt had passed.
“But it will all be worth it when he can help so many other would-be mothers.”
“Hi Rosa,” he said in a pleasant voice, though I’m sure he knew what was coming. Psychiatrists rarely introduce security staff to our patients without an underlying reason.
Compared to other areas of medicine such as cardiology or surgery, psychiatry doesn’t really have too many emergencies. We psychiatrists are used to taking our time, listening to our patient, and expecting the improvements in someone’s mind to occur over days, or more likely weeks. However, this was one of the definite psychiatric emergencies that we had been taught – a mother, delusional, with thoughts of hurting her baby, and cradling the potential victim in her arms. I was only partly trained, and would usually report back to my boss before taking any major action, but this wasn’t the time to be waiting ten or fifteen minutes for them to answer their pager. I needed to separate Rosa from Patrick, and then arrange for her detention in hospital for everyone’s safety.
I headed for the door, and asked her to follow. But the space where our security staff usually stand, available to assist us at short notice, was empty. I knew the security team well from numberless nights on call, and I understood that they were needed from time to time in other parts of the ER, but I needed them now. After looking left and right I finally saw them in the distance at the minor trauma area.
The person who was right outside the room was Rosa’s husband, Patrick Senior. I hadn’t yet spoken to him and now I needed his help. Hopefully he was going to do as I asked.
“Hi,” I said as calmly as I could, “I’m Dr Sutherland, the resident on-call for psychiatry. Can I ask you to take little Patrick for a moment while Rosa and I just go over there?”
He reached out instinctively, but she held back and was looking at me skeptically.
“Where are we going?”
“Just over to the other side of the ER where I can get you weighed.”
“Why do you need to weigh me?”
“It’s just a routine.”
This was technically true, but I would never make it part of the initial assessment, and I would rarely perform the weighing myself. However, the scales were on the other side of the ER, near where I would get the support I needed.
She didn’t move, and looked doubtful, clutching her baby tightly. My pulse began to quicken, and I wasn’t sure how to proceed if she wouldn’t hand over little Patrick. I knew that our staff would separate them, but I feared for the baby’s safety during such a struggle, and we all needed this to go smoothly.
“Here love, let me take him,” said her husband, and as she handed him over I tried to nod at him with meaning, and gratitude.
Rosa then followed me across the hall, looking back from time to time.
“Hi Steve,” I said to the friendly young man in the hospital’s blue uniform, “can I introduce you to Rosa?”
“Hi Rosa,” he said in a pleasant voice, though I’m sure he knew what was coming. Psychiatrists rarely introduce security staff to our patients without an underlying reason.
“I’m going to be detaining Rosa under the Mental Health Act, and I didn’t want to do that while she was holding her baby. That’s him, over there with his dad. Could you and your colleagues help us manage the situation?”
“Sure I can,” came the easy reply. Rosa just stood there, with the bliss draining out of her as she gradually took in what I had said. Then she slowly began to move back towards the two Patricks. Steve followed her, and as she broke into a run, he easily slid his arm around her waist and brought her to a stop.
“No!” she wailed, “My baby!” and struggled against Steve’s restraint. His colleague arrived quickly, and they soon took control and slipped her back into the interview room, which they then locked. That left them outside with me, and Patrick Junior, and his father whose face now bore a look of horror.
Postpartum mental illness is a relatively well-known problem, though most people tend to think of postpartum depression, rather than psychosis. There’s a good reason for that since it is all too common, affecting one in ten of all newly delivered mothers. Being depressed is a terrible way to start motherhood, but at least it is treatable, and patients are expected to make a good recovery. Postpartum psychosis, such as Rosa had, is much rarer, affecting only one or two women in a thousand births. There may be a mood component to the illness, but if so it’s mania, that mirror image of depression. The hallmark of postpartum psychosis is not a mood issue, but the hallucinations and delusions that take over someone’s mind and characterize the public’s typical impression of madness. Rosa didn’t have hallucinations as far as I could see so far, but her delusions about Patrick’s miraculous abilities were more than enough problem for her and us to be dealing with.
If someone is unlucky enough to have a previous diagnosis of psychosis, or a family history of it, then their risk of a postpartum episode is elevated, but many of the patients of perinatal psychiatrists find that their illness comes out of the blue, with no hint of mental disorder in their backgrounds. We don’t know for sure what causes it, but it is likely connected to the sudden drop in reproductive hormones that follows delivery of the baby, and which somehow triggers the illness.
So, there we all were. A new mother, finally emerging from the years of struggling against infertility, only to be overtaken by a mental breakdown, and on the verge of delusionally harming her child. And a new father, seeing his long-cherished dreams of having a family collapse into this nightmare of madness. Most people couldn’t picture a more disastrous situation. So, it is a sign of just what a strange profession I have, and how psychiatrists have such a skewed perspective on life, that I wasn’t feeling anything except relief and optimism. And from my side of the room there was every reason to be positive, now that mother and baby were safely separated.
Since I started my training, I had seen people suffering from psychotic disorders such as schizophrenia day in and day out, and despite our usual success at treating the hallucinations and delusions, the illness still tended to be disabling. Only one in five people suffering from schizophrenia will likely remain employed and able to live a largely unchanged life, because the negative symptoms of amotivation and flatness impair the functioning of the majority with the diagnosis. From that viewpoint, it was a pleasure to be involved in the care of a new mother with psychosis, because postpartum illness tends to respond to treatment so well, with a return to premorbid functioning in a large majority of patients. That meant that while the family was despondent, I was anything but; particularly now that little Patrick was safely away from Rosa.
“Whatever crazy things she may be saying at the moment, it’s not her but the illness talking.”
The next task was to convey this optimism to the others. By now we had arrived in the hospital’s mother and baby unit, and my boss was talking with Rosa and explaining to her the need for medication, and from the sound of Rosa’s screaming it wasn’t going well. Little Patrick was now in the care of Rebecca, the unit’s nursery nurse, which left me to talk with Patrick Senior.
“It looks terrible I know, but what I need you to understand is that this is temporary.”
His face was riveted on mine, as if I was handing out a life sentence, and thankfully in this case I wasn’t.
“Rosa is expected to get better, but this will take a few weeks. She has to stay here, and we can keep Patrick as well so that they aren’t completely separated. She’ll need medication, whether she likes it or not, but you should look forward to having your wife back again.”
There was a long silence, followed by “What can I do?”
“Visit, and don’t give up on her. Whatever crazy things she may be saying at the moment, it’s not her but the illness talking.”
In treating postpartum depression we might want to use medication, or psychotherapy, or address an underlying social problem. But Rosa’s psychosis was much more biological than psychosocial, and treatment for her meant a mixture of medications. We used antipsychotic drugs to block the overactivity of her brain’s dopamine and hopefully stop her delusions. And we also used lithium carbonate, that longstanding treatment for bipolar disorder, since postpartum psychosis appears to have so much in common with a manic episode.
Rosa didn’t have the easiest of journeys through her hospital admission, and I still have memories of the security staff chasing her around the inpatient unit, and with me following with a syringe to inject her. But with time she began to change.
First her behavior calmed down, and then it was possible to sit with her and have a conversation. But the content of what she talked about remained as delusional as ever. She told me that little Patrick was given to her by God so that she could cure so many other infertile couples. She didn’t want to harm him, but she believed it was God’s will, and so would go ahead with it when she had the chance.
Then over time we could see her psychotic thoughts gradually retreating. She began to think that Patrick didn’t need to lose fingers to cure others, but just a visit from him would do it. Next, she gradually slid into thinking that she would be a useful resource talking to women struggling with infertility since she had successfully conquered it, and seeing Patrick would be enough to encourage others to continue, without having to harm him.
Although I appeared so professionally wise to Rosa and Patrick when I told them how to expect a good recovery (or at least I hoped that I did), I was still very green, just three years into my training, and the magical difference that blocking a single neurotransmitter could make to someone’s psychosis was still a small miracle to me. I woke each morning eager to see just what new improvement I would find when I sat down with Rosa for my daily interview. And after three weeks of antipsychotic medication, she finally offered me some insight.
“I was insane, wasn’t I?” She asked, with none of her previous elation.
“’Delusional’ is probably the better word,” I answered, “but your mind was certainly not thinking right.”
“But why? Did I do something to cause this?”
“No Rosa, it was nothing but bad luck. This happens to a small number of new mothers, and it’s nothing that any of them have caused.”
“I can’t believe that I would have hurt Patrick.”
“No, it seems almost impossible for anyone to do that. And we’re not convinced that you would have hurt him, because you still retained some understanding that it was wrong. But the risk was certainly too high.”
“Will it happen again?”
“Probably not in ordinary life. You never had such a problem before, and so you should be OK. However, there is a definite risk that the same thing would happen in another pregnancy. As and when you think about having another child you would need to involve us early on to minimize the risks.”
“Another pregnancy?” She smiled ruefully. “You must be joking, I can’t even think about it.”
One more week of hospitalization allowed her to complete the gradual tests of passes back home with her husband. These went smoothly and without incident. Within the ward we were now letting her care for little Patrick independently. Rebecca kept her distance, but her eyes were quietly watchful, and she reported back to us that Rosa was mothering wholly appropriately.
On the day of her discharge, I signed Rosa out from the ward and watched the family leave. Seen from a distance they once again made an idyllic picture. Looking down the corridor, I saw them pause at the point where the mental health wing meets the rest of the hospital. They were overloaded with the usual baggage train of belongings that slows all parents, and they took a moment to rearrange things for the final walk to their car. Rosa readjusted her hold on the baby, and briefly leaned in towards her husband. I saw him kiss her on the head, and smile at little Patrick. Then, shoulders squared to better carry their burdens, they walked off without looking back, and entered their future as a new family together.
All names and other identifying details have been changed to protect patient confidentiality.
This piece was previously published in the journal Intima.
JP Sutherland 