The Madness of Childbirth

The North Wales asylum made its way into my life by accident. The history department at Bangor University secured a grant to look at the social impact of the asylum. Looking at the records they collected, it was striking how people declared their madness a century ago – they tore off their clothes and escaped through windows, which they never do now.

But when we set about entering North West Wales records from the asylum in 1896 to compare with admissions in 1996, something more startling became apparent – we admit 15 times more people with serious mental illness now, and compulsorily detain 3 times more people (Healy et al 2001). This prompted a quixotic adventure – why not enter all records from North West Wales between 1875 and 1924 and build a modern database covering admissions from 1994 to 2010?

This was quixotic because no-one wanted to fund us. Grant-giving bodies in history were not able to see the value in quantifying records or in having modern data. Modern epidemiologists could not see the value in historical records. So over 15 years and without support we put together easily the largest body of historical epidemiology in existence – we had no competition, no-one else thought this made sense.

North West Wales is uniquely suited to what we did. It’s surrounded by the sea on 3 sides and the mountains on the fourth. The population remained almost exactly the same between 1896 and 1996. It was then and is still now almost exclusively Welsh. It was rural and never urbanized. The people are poor and so there is no private care. There was then and is now only one place to go for a hospital admission. In the case of the few people who left the area, through the National Health Service we have been able to track everyone down so not a single person is lost to follow-up.

Almost God-given for our purposes. This is where Tolkien set Middle Earth. To the South East looms Mordor which casts a long shadow – suggesting a Pharmageddon to come.

The response from some experts to our findings has not been unlike the dismissive attitude of Orcs or Black Riders to Hobbits. They sneeringly fall back on the fact that we have made diagnoses based on century old records. One hostile reviewer argued that when black men in America in the 1960s could be detained compulsorily and diagnosed as having schizophrenia, what chance is there our records have it right. Others are sure women with unwanted pregnancies were incarcerated in mental asylums and diagnosed as schizophrenic.

The ultimate proof that out methods are right lie in a set of  bricks and mortar developments, as will become clear.

Postpartum (or puerperal) psychosis was one of the severest mental illnesses ever. It accounted for the admissions of one in ten of the women of child-bearing years admitted to the old asylums between 1875 and 1924. It came in two forms. The most dramatic form happened in women who had never had a hint of mental illness before, who were stably married and well-placed who within a week or two of giving birth to their first or fourth or other child went floridly mad. These women with de novo onset postpartum psychoses accounted for 4 out of every 5 cases. Their psychosis looked completely different to either schizophrenia or manic-depressive illness.

The second group were women who had had a previous mental illness who after giving birth might have a further episode of essentially the same illness they had before. Their illness typically looked like a further episode of manic-depressive illness.

When the asylum closed it was replaced by 3 district general hospital units, across North Wales, the Hergest Unit in the West, Ablett and Llyn-y-Groes in the middle and East. All 3 had mother and baby units. These units were opened up because of the rates of admission for both kinds of postpartum psychosis in our asylum records – these map directly onto what was in 1993 the accepted rate for the occurrence of post-partum psychoses.

Hergest was the first of these general hospital units to open but within 3 years of opening, the mother-and-baby unit closed. There were no cases. The Ablett mother and baby unit had just opened up and this is where Cora went (see Cora’s Story)– and going there may have partly caused her loss of life. All 3 mother-and-baby units have now closed.

Our historical and contemporary databases bring this out perfectly. De novo onset postpartum psychoses have vanished – the manic-depressive type remains (see Tschinkel et al 2007). These are not disorders you can treat in the community. They are the most high risk in all psychiatry.

But when we came to report the findings we were in for a surprise. No-one it seems wanted to hear about a disorder vanishing – not the postpartum experts whose careers depend on it and are still busy portraying it as commoner than ever. Not the health service managers whom one might have thought would have an interest because of the budgetary implications. Nor the researchers you might have thought would be interested in the implications for theories of mental illness. Not the historians specializing in postpartum psychoses or women’s mental health. It was difficult to get published.

What our critics fail to realize is that we are not going on historical or contemporary records. Doctors in the nineteenth century made diagnoses based on how the patient looked when they walked in the door but we have had the entire lifetime medical record of these patients available to us and could base our diagnoses on these.

Doctors today don’t make diagnoses on the patient as they walk in the door. When the patient is discharged, the ward clerk or someone with no medical training typically enters the diagnostic code into an administrative database. This can work very well in medicine, but doesn’t make sense in psychiatry. A great deal of modern psychiatric epidemiology is based on diagnoses like these – close to useless. Other studies are based on diagnostic interviews instead, which are also close to useless. Almost 50% of cases of schizophrenia, as clear cut a condition as psychiatry has, get a different diagnosis during their first year or two of admission. It takes time for the nature of the illness to become clear. And this is where our approach scores for both historical and modern cases – we make our assessments based on the full clinical record with input from everyone who knows the patient.

There has been extensive work by others on historical records at this point. These have revealed several famous examples of individuals who may not have been mad and who have protested against their incarcerations. But these are exactly the cases that we do not diagnose as having had a psychosis. If a Black or Irish man had been inappropriately incarcerated in North West Wales in 1896 we would have spotted it. In fact the asylum records show clinicians sensitive to issues of whether this patient was “a knave or a fool”.  They were very reluctant to admit and quick to discharge knaves. There was not a single admission for unwanted pregnancy or ethnic factors, and in cases where there was domestic or other abuse, these issues were clearly flagged up, making it possible for us to take this into account retrospectively.

The abuse of the asylum by doctors was a mid-twentieth century phenomenon – a telling example of how medicine can turn to the dark side rather than sustain progress. But just because the Nazis exterminated mental patients and psychiatry acted like an agent of the State in both the Soviet Union and the West in mid-century doesn’t mean it was always this way. Life in the Shire, if not perfect, was once good enough. The challenge has always been to keep it that way – although a case can be made that things are getting even worse now.

So what happened postpartum psychoses? We have no idea. This is in complete contrast to catatonia which has also vanished and we are certain we can explain this. It’s also in contrast to schizophrenia, where we have some good ideas.

What could have happened? The postpartum psychoses look more like steroid psychoses than schizophrenia. Perhaps their disappearance stems from the active management of labor now which means few women get as fatigued as once happened, or the use of pain relief like Heroin (see Tschinkel et al 2007). If post-partum psychoses are related to catatonia, the availability of benzodiazepines might be expected to make a big difference. Whatever the reason, our best guess is this condition began to disappear somewhere between the late 1970s and the 1980s. We want any suggestions anyone can offer.

13 COMMENTS

  1. Hi. I have a friend who was mentally ill for the first time in her life after childbirth. There was also a recent episode of Newsnight on the BBC, detailing post-pueral psychosis (the subject matter of the programme was also covered on Radio 4) and one woman of the three interviewed had suffered psychosis for the first time, after the birth of her second child. So surely the condition has not entirely disappeared?

    (I also had post-pueral psychosis, after the birth of my first child, but I had a previous diagnosis of schizophrenia, which was taken as the explanation. I have been well ever since. That is beside the point, but I mention it to explain my interest in this subject).

    So, have you really not heard of any episodes of psychosis following childbirth, in people who have not been previously mentally ill? I have at least two other friends who suffered psychotic symptoms, although not the full-blown illness – in my opinion sleep-deprivation and hormonal factors triggered these experiences.

    All the best
    Louise Gillett (author of Surviving Schizophrenia: A Memoir).

    • Hi Louise – I had 2 episodes of puerperal (postpartum) psychosis in 1978 and 1984 without any prior mental ill health diagnoses/labels. Here is my response to this David Healy post on his own blog:

      “I had episodes of postpartum or puerperal psychosis in 1978 and 1984, after the painful births of my second and third sons. I didn’t have it in 1976 after the birth of my first son, when I had good pain relief, a spinal anaesthetic injection at Ninewells Hospital, Dundee. All of this happened in Scotland and I am Scottish.

      With every childbirth I was induced, because I was overdue but also to bring about the births during the day shift when more nurses were on duty. In 1978 and 1984 I gave birth in a local small hospital in Lanark, very little pain relief, with induction chemicals pumped into my veins. The labour pains were immense, like being halved up the middle. The actual childbirth was fine. But the trauma of the labour induction and pain meant I had a psychosis, in 1978 13wks after childbirth. In 1984 one day after coming out of the maternity hospital.

      I went voluntarily into the psychiatric hospital, had to leave my babies at home, very difficult as I was breastfeeding. Grabbed and jagged on both occasions, forced to take the chlorpromazine, then in liquid form then in pill form when obedient. It took me a year both times to get of the drugs and get back on with my life.

      I was then in good mental health for 18yrs. I’m an upbeat sort of a person, strong and resilient. Then in 2002 aged 50 I started the menopause, was in a busy job where a bullying issue was rife in the organisation, although I wasn’t bullied. Other pressures also. Hormone imbalance brought on another psychosis. Went voluntarily into the local hospital, Stratheden, NE Fife. Took a look round the mixed ward, decided to leave, was sectioned for 72hrs.

      Knew I would have to take the drugs or be grabbed and jagged. So swallowed the risperidone. It brought me quickly out of the psychosis, as usual the neuroleptic depressed me. Was only in the acute ward for about a week. I was put on venlafaxine for the depression, it depressed me more, I overdosed. Got back from Ninewells, the psychiatrist put me on maximum venlafaxine. Still flat and unmotivated. But taking an overdose had scared me, very unlike me and I seemed to do it on impulse, I made conscious efforts to not do it again.

      The psychiatrist decided to put me on lithium, to ‘augment’ the venlafaxine. He tried to diagnose me bipolar, I resisted, so he put schizoaffective disorder on my notes. Although I disagreed I wasn’t listened to. Eventually I decided to take charge of my own mental health, started doing various volunteering activities. Not easy as I was very unmotivated, sluggish, mornings were worst.

      Gradually started to feel better, by this time the psych had taken me off the risperidone. So I started tapering the venlafaxine, got off it OK, this was in 2003/4. Which left the lithium. I told the psych that I’d be reducing and coming off it. He said I had a lifelong condition requiring it. I disagreed and decided to taper at 200mgs a month, I was on 800mgs/daily. I got off it all without any side effects. And got back on with my life.

      The schizoaffective disorder label is still on my notes, sticking like glue and affecting the psychiatric treatment of my sons who also have experienced psychotic episodes, and completely recovered. But I am now an activist and campaigner in mental health matters. Changing and improving the psychiatric system where I live and trying to have an influence nationally.

      I’m 60 now and a granny and I don’t want to see my grandchildren having to go through what I did in a flawed psychiatric system. Being forcibly treated and paternalistically patronised.”

      • Hi Chris

        So sorry it has taken me so long to reply – I have not been on this site since I commented on this article. I was not even sure when I commented if I properly understood what David Healy was saying – I will have to look at his own blog too.

        I am so glad to have heard your story, because it has so many lessons for me (and I’m sure universally). For a start, although I think I have fully recovered my mental health, I am aware I should not be complacent – I will now be especially guarded around the time of the menopause.

        I am sad to hear that your children have also suffered mental ill health. I hope that I can somehow protect my own from this – by being watchful and by loving them and protecting them as much as possible – but I am aware that I have no power over their futures.

        I still do not believe that mental illness is hereditary (probably because I don’t want to believe it). But the important thing is that your children have fully recovered, and I am sure you have been instrumental in that, because of your experience and knowledge of the subject. So I can learn from that too (although I hope I never need to put that lesson into practice).

        I am so pleased to hear you are off medication. Sometimes I feel like the only person in the world who has come off it – although of course I know otherwise through the internet. I have been posting on the Rethink Talk forum recently, and a chap wrote in response to one of my posts that he felt personally insulted when people ‘claim to have recovered from schizophrenia’ – this really hurt. I know medication works for some people, despite the side effects, but I feel that more people could manage without it, especially if they were helped to do so by the mental health professionals.

        And yes, activism and campaigning is really important – hard at times, because these labels hurt even though we know they have no place in our current existence. But keep up the good work Chris -and I will keep learning from you!

  2. You haven’t read Patrick and Henry Cockburn’s recent book “Henry’s deamons” -a father and son’s journey out of madness. When Henry gets hospitalised he is in the habit of tearing off his clothes and escaping through windows. The book has been written in 2011.

    • I have read that book, and met Henry and Patrick and had dinner with them (through my recent author talk at Newcastle University, associated with the ‘Reassembling the Self’ exhibition). See my blog ‘Schizophrenia at the Schoolgate’ for further info.

      Henry and Patrick also spoke about their book, and when I asked Henry afterwards whether he thought he would have fared better with a diagnosis of bi-polar disorder (in light of his creative talents) he told me he was ‘Proud to be a Schizophrenic’. This, I found sad – anyone who identifies themself as schizophrenic and agrees with the diagnosis has no chance of recovery, because one is told that one has a degenerative ‘brain disease’ that is a lifetime condition.

      To get better, you have to move outside the psychiatric system and reject their view of you as diseased. I don’t mean that people should unilaterally stop their medication and cut off from all medical support (I only ever stopped my medication under the auspices of medical professionals; I was lucky they allowed me to try). Just that you have to take a different view of yourself – as a human who has the potential to be whatever he or she wishes. Then you can work towards recovery – and you might be amazed at what you can achieve.

      ‘Henry’s Demons’ is certainly worth a read though. My favourite quotes are Patrick’s, but Henry’s parts are also very well-written. Patrick points out that mental health treatment in this country is a hundred years behind the treatment of physical health, and he also says of schizophrenia that, ‘Violence is not a symptom’. Simple but profound statements.

      I would love to read a sequel one day which shows that Henry has regained full health – but first he will need to give up his (in my opinion) misplaced pride in his label.

      Louise

  3. “So surely the condition has not entirely disappeared?”

    Why do we assume a “condition,” rather than a continuum of nervous system responses to traumatic experience?

    All clinical “data,” (a term which is highly suspect, considering diagnosis is not objectively, but subjectively defined) include assumptions of what the observer thinks they are witnessing, with following write ups that can include the lazy use of language. Example:

    “So what happened postpartum psychoses? We have no idea.” writes David Healy to add dramatic effect to his essay. Yet from the very study he cites we read;

    “Possible contributory factors to a changing admission prevalence for postpartum psychoses include the active management of labour
    leading to less exhaustion. The local rate for caesarean sections is high. In addition, the local obstetric unit provides morphine-based pain relief rather than less potent analgesia. Another
    factor may be a liberal prescription of benzodiazepine hypnotics postpartum; given that benzodiazepines are very effective for motility disturbances such as catatonia, it may be that these measures prevent the evolution of a classic cycloid picture.”

    “The local rate for caesarean sections is high. In addition, the local obstetric unit provides morphine-based pain relief rather than less potent analgesia.” Do these local “conditions” account for the drop in postpartum psychoses, if we don’t assume separate and definable medical conditions, and use a continuum of nervous system response to pain, approach to so-called mental illness?

    Why do we use this mechanical logic of ascribing a “this or that” medical condition, and deny the possibility of a continuum of traumatic response? Why do we dismiss the “overlap” within these so-called separately definable conditions, and never look at the body’s role (nervous system feedback) in emotional/mental anguish? Yet in trauma resolution work on that separately definable medical “condition,” PTSD, new attitudes to the role of the autonomic nervous system in self-regulation are leading the way forward in effective treatment? SEE: “Mind-Body Skills for Regulating the Autonomic Nervous System” http://www.dcoe.health.mil/Content/Navigation/Documents/Mind-Body%20Skills%20for%20Regulating%20the%20Autonomic%20Nervous%20System.pdf

    Excerpt;” An important component of overcoming trauma is learning to regulate one’s physiological arousal in response to reminders and to fully engage in one’s present experience, as practiced in exposure based interventions. Currently, cognitive behavioral interventions and psychopharmacological approaches for regulating anxiety and emotions have predominated, but various mindbody approaches have shown promise to positively affect a variety of disorders, including anxiety, depression, headaches, chronic
    pain and insomnia. The clinical literature on the treatment of PTSD and other stress and anxiety disorders consistently suggests that being able to regulate affective arousal is critical to coping with the *traumatizing experience*. The new VADoD Clinical Practice Guidelines for PTSD acknowledges the potential role of many integrative modalities as augmentation strategies in the treatment of symptoms related to PTSD, particularly symptoms related to hyperarousal. In addition, it suggests that these modalities may foster a “patient centered approach to care that leads to greater willingness to engage in and continue with care.” I would imagine that giving could be a *traumatizing experience* and I suggest that the majority of so-called mental-health “conditions” can be viewed on a continuum of nervous system response, and that its the autonomic nervous system which defines the “overlap” cited in this paper.

    “The overall picture outlined here is ambiguous. While the trigger to postpartum psychoses is unique, the data regarding its course and typical features are more complex. An absolute distinction in terms of clinical features is not needed for a distinct disorder; thus while there is clearly some overlap in the clinical features between de novo onset postpartum psychoses
    and both schizophrenia and affective disorders, there was also overlap between the psychosis of general paralysis of the insane and schizophrenia, such that Kraepelin reported that it was difficult to make the diagnosis on a crosssectional basis.”

    “Whatever the reason, our best guess is this condition began to disappear somewhere between the late 1970s and the 1980s.” Perhaps correlating the changes in local birthing practices, leading to a less traumatic experience might shed some light?

  4. Other comments I’ve just put on David Healy’s own blog website post:
    http://davidhealy.org/the-madness-of-childbirth/
    which are “awaiting moderation”:

    “Let’s not pathologise human distress and a mother’s pain at childbirth, the effects of which can lead to psychiatric incarceration and forced treatment. I managed to recover from the force, treatment and labelling. Others have not been so fortunate.”

    “Psychiatrists back in 1978 said to me that my puerperal psychosis was due to hormone imbalance, they were quite clear about this, and therefore I was allowed to recover without any diagnosis or label on my notes. Same thing in 1984.

    The difference came in 2002, after a menopausal psychosis, where I was given a cocktail of drugs and diagnosed schizoaffective disorder, a label that remains to this day and which psychiatry will not remove. Although I maintain it is a wrong diagnosis and only a subjective opinion. For I recovered completely, from mental ill health, psychiatric drug use and the influence of the psychiatric system.”

    “As a woman who has given birth 3 times I say that post partum conditions have everything in common. The pain of childbirth, especially with the chemicals sometimes forced into our body, as in induction chemicals, are both traumatic.

    You’d need to have a baby to see what if felt like. Especially to see what it felt like being induced to fit in with the nurses’ schedules and the doctors on duty. A bit like psychiatry that tries to make us fit in with the psychiatric system. A failed paradigm which has to use force to get its own way.”

    I’ll let you know if they pass the “moderation” test.

  5. I’m thinking the moderator might be on holiday as it’s a 2wk school holiday here in Scotland (used to be the ‘tattie’ holidays, as in potato picking), lots of workers on holiday, not sure about Wales though.

    Just checked and Bangor, Gwynedd, North Wales, school half term is from 29 October, so they don’t seem to be off on holiday at present.

  6. Yep, and it is damned good stuff, Chrys! The comments you and others have made, about traumatic birth and disruption of the mother-baby bond in hospitals, are a big contribution to this discussion.

    As far as whether classic postpartum psychosis is disappearing … it is so hard to tell, especially in the US where every form of “mental illness” is overinflated and hyped by someone with a profit motive. Currently they want to mash together any emotional distress between the time you get pregnant and your child’s first birthday as “perinatal mood disorder.”

    A few of the most high-profile tragedies involving mothers who kill, like that of Andrea Yates, may actually be due to antidepressants. Ms. Yates was on her fifth child and had had psychotic reactions to the births of #3 and #4, I think … and she was put on Effexor.

    Looking forward to your next column!

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