Stories about infanticide are heartstopping and thankfully rare occurrences. But when we are confronted with infanticide, and in this case, allegedly serial infanticide which may have occurred across a decade, we must again consider how and when we decide that a pregnancy or postpartum mood disorder had any role in these infant deaths.
It is gratifying that one reporter from the Salt Lake City Tribune, Lindsay Whitehurst, made it her business to speak to those who could help guide the public’s impression away from a simple diagnosis of postpartum depression.
This tragic situation underscores a reason I was unable to support the “fix” in the DSM about extending the postpartum onset specifier to six months or even a year. This narrow extension to the period in which a woman may be vulnerable to a mental health issue entirely misses the point. Up to 20 percent of all women will experience a major affective mood disorder sometime throughout their life. We have no way of responsibly attributing the true etiology of postpartum illnesses to pregnancy and delivery if we have not been assessing that mother for mental health issues throughout her life. The diagnosis of ANY medical condition requires an understanding of all presenting symptoms, when they began and their duration. Onset is only one piece of the puzzle.
Women’s reproductive mental health begins at menses and ends at menopause. We understand that these can be periods of emotional vulnerability for many women. Biology does indeed play a role in the emergence of depressive episodes as it conspires with environmental factors to create the perfect storm in susceptible individuals.
Without a benchmark, or any understanding of a woman’s mental health prior to consideration of pregnancy and childbirth, we may be misassigning emergence of these disorders to a pregnancy when in fact the pregnancy is only an exacerbating factor and not a causative one. Assumptions not based in a more extensive overview of a woman’s mental health history could lead to undertreatment, causative misattribution and poor treatment outcomes. It can also lead to the inaccurate conclusion that any negative or harmful behavior demonstrated by a mother to her infant is due to a postpartum mood disorder.
Women’s mental health does not begin and end with pregnancy. Until we are consistently evaluating and assessing mental health issues as part of annual physicals across a woman’s reproductive life cycle, we cannot reliably attribute these illnesses to pregnancy and postpartum alone. We cannot use data which takes a snapshot of only one phase of a woman’s life to form important conclusions about etiology.
Nor do evaluations specifically developed to assess maternal mood disorders control for sociopathic or criminal behavior which might co-exist with a postpartum disorder. Having fought for decades to develop appropriate responses to women suffering from perinatal mood disorders, we must be careful that our lense does not become so narrowly focused on a time frame that we miss who the mother is and was before her pregnancy.