Postpartum Psychoses and Drugs

July 3, 2001 -- In the wake of the Texas tragedy in which Andrea Yates allegedly drowned all five of her young children, many are left wondering what happened to this woman and her family.

Yates' husband, Russell, said his wife had been suffering from postpartum depression, and had previously taken several types of antidepressant medications including Effexor, Remeron, and Wellbutrin.

He also said his wife had been on the drug Haldol, a powerful anti-psychotic medication used primarily for treating schizophrenics. It remains unclear whether she was on the drug at the time of the killings.

Either way, Haldol indicates Yates may have been suffering from a much more serious disorder than depression, experts say.

Yates' brother Andrew this week expressed concern that his sister "was taken off medication she should have been on." Although he said he could not go into details, many assume he was referring to Yates' Haldol treatment, since Russell Yates stated his wife had taken the drug in the past. Yates' attorney said he could not confirm whether his client had been taken off the drug.

Different Postpartum Mood Disorders

About 50 percent to 75 percent of all mothers experience a mild form of depression called the "baby blues," which typically comes on within the first few days following childbirth, lasts for several weeks at most, and is marked by crying spells and feelings of sadness, anxiety, and irritability.

Another 5 percent to 10 percent of mothers go through "postpartum depression," characterized by deeper sadness and anxiety, depression, hopelessness, exhaustion, guilt, and a general feeling of being "not yourself." This type of depression ordinarily begins within weeks or months of birth, increases slowly over time, and has a longer duration than the baby blues.

Much less common is "postpartum psychosis," which is suffered by fewer than 1 percent of all mothers. Symptoms for this disorder are similar to other forms of psychosis, including hallucinations, mania, delusions, altered mood, extreme confusion or agitation, paranoia, and disorganized thinking. Postpartum psychosis has a very rapid onset, usually within the first one to three days following childbirth.

Experts agree that postpartum psychosis is likely triggered by the rapid fall in hormones, such as estrogen and progesterone, which follows the birth of a child. It is believed this fall in hormones activates a cascade of chemical events within the brain that ultimately lead to psychotic thoughts and behaviors.

Psychotic thoughts can also occur with severe depression after childbirth, though the onset of delusional symptoms is much slower than classical postpartum psychosis, which comes on very quickly with dramatic and obvious changes in behavior.

Psychosis with depression is more insidious in nature, with symptoms that gradually worsen over a period of weeks. A mother may begin with the more common form of postpartum depression, but then progressively develop psychotic symptoms as time goes on.

Could the Tragedy Have Been Prevented?

In general, doctors say it is difficult to predict if a new mother will suffer postpartum psychosis, though women with bipolar disorder or mothers with a history of severe postpartum depression are more at risk for developing psychotic tendencies after pregnancy.

Given Andrea Yates' known history of major postpartum depression and possible psychosis following the birth of her fourth child two years ago, her alleged current break with reality is then much less surprising, experts say. By some standards, it may even have been anticipated.

"The strongest predictor of a future episode is whether a woman has had previous symptoms," says Dr. Kim Pearson, a psychiatrist specializing in postpartum depression at both McLean Hospital and Massachusetts General Hospital's Perinatal Reproductive Psychiatry Unit. "Mothers who have suffered one episode of postpartum psychosis have a 75 percent chance of experiencing another episode following their next child."

Considering the chain of events and details shared by the Yates' family, Yates may have been experiencing major depression with associated psychotic symptoms triggered by the birth of her last child six month ago.

Yates' husband said he had noticed his wife behaving "withdrawn, robotic," and with particular "nervous habits" that he recognized from a previous bout of postpartum problems.

For people with temporary psychoses, the way they talk, think, and act will seem "off," as if they are "not themselves." Friends and family may notice a mother being anxious, confused, suspicious, irrational, hyperactive, speaking differently, or becoming overly focused on "the little things." For example, a person may develop small, seemingly meaningless rituals, or attach extra meaning to things in their environment, places, or events.

Haldol and Postpartum Syndromes

Haldol, also known as haloperidol, is most commonly prescribed for treating schizophrenia and other psychological disorders with strong psychotic components. It is therefore used primarily to treat the serious symptoms related to postpartum psychosis and not for the more common postpartum blues or depression.

Haldol is a type of neuroleptic drug that acts within the brain by blocking the activity of the chemical dopamine. It is believed that an over-abundance of dopamine within certain areas of the brain is what induces disorganized thoughts hallucinations, and paranoia. Other neuroleptic drugs used for these symptoms include Thorazine and Clorazil.

While the potential harmful fetal effects of using Haldol during and after pregnancy are not completely known, the drug is generally considered to be safe and effective for pregnant women pre-disposed to experiencing postpartum psychosis.

"Haldol can be used safely during pregnancy and, when indicated, should be taken prophylactically to prevent postpartum psychosis," says Pearson. Patients at high risk can be started on the drug within the final two to three weeks of gestation.

Pearson strongly recommends women taking Haldol or any other anti-psychotic medication be monitored closely by a psychiatrist, and use the drug in conjunction with psychiatric therapy.

"Usually the first doctor to notice postpartum psychosis will be the ob-gyn or pediatrician. Ideally, a mother will then be referred to a psychiatrist who can make a proper assessment and provide treatment."

Haldol Effects

Patients taking Haldol can experience a number of physiological side effects including restlessness, fatigue, dry mouth, constipation, and even involuntary movements similar to those seen with Parkinson's disease, so it is important to see a physician on a regular basis. Psychological side effects, however, are quite rare.

The length of time a patient remains on Haldol varies greatly and can be decided only by patient and physician. Women taking Haldol for relatively short periods should not worry about withdrawal effects after discontinuing drug therapy, though patients on high doses for long periods may suffer temporary irregularities in body movement.

But experts say patients and their families should be aware that stopping medication too suddenly may cause a return of the same psychotic tendencies that initially brought them to therapy.