Built for the Wrong Illness

Most women in this country give birth in a county without enough maternal mental health providers. Roughly 96 percent of American women of childbearing age — about 62 million people — live in a maternal mental health professional shortage area. The shortage is measured, mapped, and published every year. What is harder to find on those maps is the illness that does the most damage fastest, because American psychiatry has never formally given it a name.

In the Diagnostic and Statistical Manual of Mental Disorders, postpartum psychosis does not exist as a distinct, standalone diagnosis. Clinicians who study it have argued it should be classified on its own, and some have proposed moving it into the manual's bipolar chapter. Instead, American psychiatry records it as an onset specifier attached to some other diagnosis — a brief psychotic disorder, or a mood episode with psychotic features — where onset falls during pregnancy or within about four weeks of delivery. As a primary medical entity, it is officially invisible.

The illness itself is neither rare nor mysterious. Postpartum psychosis occurs in one to two of every 1,000 births. It comes on fast — delusions, hallucinations, a break from reality in the days or weeks after delivery — and it usually requires inpatient care, sometimes involuntary. It is also treatable. In the largest prospective study of its treatment, 98 percent of hospitalized patients reached remission on a stepwise regimen of benzodiazepines, antipsychotics, and lithium, and every participant who reached the lithium stage recovered. The tragedy of postpartum psychosis is not that medicine lacks a cure. It is that the system consistently fails to find it.

The screening process relies on standard intake questionnaires handed out in waiting rooms. The American College of Obstetricians and Gynecologists recommends screening at the first prenatal visit, again later in pregnancy, and at postpartum appointments; pediatricians screen mothers at well-child visits through the baby's first six months. Usually, this means handing a patient a ten-question form, such as the Edinburgh Postnatal Depression Scale, which asks how often, over the past two weeks, she has been able to laugh, look forward to things, or feel overwhelmed. A score of ten or higher flags a positive screen and triggers a closer look. Nobody in the clinic is cutting corners; the protocol is being followed to the letter.

But the EPDS's own documentation notes that it was built to detect a disorder "less severe than puerperal psychosis." The tool is simply aimed at a different target. ACOG's 2023 Clinical Practice Guideline does address acute postpartum psychosis — it names it as a medical emergency. What the guideline does not provide is a way to screen for it, because the symptoms come and go and no test reliably catches them. So the emergency is named in the guidance and absent from the form. It isn't that screening is useless; it catches depression, which millions of mothers experience. It is that the net cast so routinely was never meant to catch this.

In December 2015, Meghan Cliffel was riding the subway home from work in New York when she became convinced the other passengers meant to harm her and her two daughters, then two years old and eight months old. At home, the delusions spread — the refrigerator was releasing fumes, the people on television were threatening her. She hid all of it from her husband, because she could not be certain he wasn't part of it. She spent twelve days in a psychiatric hospital. Staff suggested she might have bipolar disorder. The postpartum psychosis diagnosis came two months after that, and she has described what it gave her simply: "That moment of somebody naming it was so helpful to me."

Lindsay Clancy was a labor and delivery nurse in Duxbury, Massachusetts. She saw psychiatrists, entered an outpatient hospital program, and spent five days as an inpatient at McLean. She told providers she was having suicidal thoughts. She was prescribed benzodiazepines, Trazodone, Zoloft, Valium, Seroquel, and Remeron. According to trial testimony, one provider raised the possibility of a mood disorder or underlying bipolar disorder, but none appeared to identify postpartum psychosis. Dr. Jennifer Tufts, who treated her by telehealth beginning in September 2022, testified that she did not have Clancy's complete medical record and had not sought records from her recent outpatient treatment — she trusted her patient to volunteer anything relevant. Tufts learned of Clancy's January inpatient stay only after she was discharged.

Neither woman was turned away. Both were inside the system, being seen and being treated. Only one of their names is known.

I'm not here to pass judgment on a trial the legal system itself could not resolve. Weeks of testimony, more than eighty witnesses, and opposing panels of psychiatric experts ended in an 11–1 deadlock and a mistrial. The jury didn't fail — it mirrored a system with no coherent framework for evaluating this illness. The district attorney is still weighing a retrial, with motions pending in November. The absence of a verdict is not a chapter to debate. It is the same gap, showing up in a courtroom.

The law has the same problem as the manuals. In England and Wales, the Infanticide Act of 1938 recognizes that childbirth-related mental illness can extend through a child's first year; cases brought under it rarely end in prison, and commitment for treatment is the norm. Roughly thirty countries have some version of it. In the United States, one state does. Illinois made postpartum depression and psychosis a mitigating factor in 2018, but only at sentencing, after a guilty finding. Everywhere else, the only route is an insanity defense written for a different kind of illness. Even advocates for the Illinois law disagree about whether new statutes are the answer when an insanity defense already exists.

The gap does not only live in manuals and statutes. Women conceal symptoms because disclosure carries risk — the fear that saying the words out loud could cost them their children. Concealment makes the illness harder to find, and the cases that surface anyway are the worst ones, which gives the next woman one more reason to stay quiet. Cliffel hid her delusions from her husband because she could not be sure he wasn't part of them. Plenty of women hide them from their doctors for reasons that are entirely rational.

I am seventeen. The women being handed those questionnaires are about a decade older than me, which means that in ten years they will be my friends, and eventually they will be me.

So here is what this case has already taught girls my age. That seeking help and receiving it are not the same thing — Clancy saw psychiatrists, went inpatient, said the word suicidal out loud, and none of it located the illness she had. That being inside a system is not the same as being seen by it. That the honest answer to a question can cost a woman her children. And that you cannot ask for help with something that has no name, which is why Meghan Cliffel remembers the exact moment someone finally gave hers one.

Patrick Clancy told The New Yorker in 2024 that he had not been married to a monster; he had been married to someone who got sick. That distinction is the one this system is worst at drawing, and it tends to get drawn late, after something has already happened. Next week, in waiting rooms across the country, women will be handed ten questions asking whether they have been able to laugh in the past two weeks, whether they have looked forward to things.

They are good questions.

They were written for a different illness.

If you're thinking about suicide, call the confidential 988 Suicide & Crisis Lifeline 24/7 at 988. Postpartum Support International's helpline is 1-800-944-4773. If you're having a medical emergency, call 911. If you fear for your safety or your child's safety, get help immediately. If you are experiencing any of these or other symptoms, talk to your healthcare provider right away.

Sources

Bergink V, Burgerhout KM, Koorengevel KM, et al. "Treatment of Psychosis and Mania in the Postpartum Period." American Journal of Psychiatry, 2015;172(2):115–123.

Policy Center for Maternal Mental Health, 2023 Maternal Mental Health Provider Shortages & Population Risk Report; and Universal Screening for Maternal Mental Health Disorders issue brief.

American College of Obstetricians and Gynecologists, Clinical Practice Guideline on the screening and diagnosis of mental health conditions during pregnancy and postpartum (2023).

Edinburgh Postnatal Depression Scale, scoring documentation and background.

WBUR, "Clancy trial highlights postpartum psychosis and barriers to care for mothers," August 12, 2026.

WSIU/NPR, "Doctors and women who've had it call for more attention on postpartum psychosis," August 16, 2026.

ABC News, "Lindsay Clancy's psychiatrist testifies she didn't have access to her complete medical record," August 2026.

CNN, "A timeline of Lindsay Clancy's postpartum struggles, killings and legal case," October 4, 2026.

Boston Globe, reporting on postpartum law and the Clancy case, August 1, 2026.