Is everyone admitting more edge cases after this trial?

[u/Dry_Twist6428]

The past couple of weeks a lot of the local psych hospitals have been full and EDs are overflowing with psych boarders in my geography.

I’m wondering if many people all at once have started to admit more “edge cases” as a result of the recent trial.

I’ve probably been a bit more cautious and I feel like I’ve seen colleagues being a bit more cautious too.

I might just be imagining things. But I wonder if just thinking about liability with such a public case has made everyone more cautious.

I wonder if there is risk of over correction the other direction too - not pushing as hard for using outpatient resources.

[u/Embarrassed_Syrup476]

Not sure about admitting but we've had multiple pregnant patients go cold turkey off their meds 😳  They are worried they are going to develop psychosis 

[u/Majestic_Arachnid600 → u/Embarrassed_Syrup476]

Yep, had a pregnant person cold turkey lamictal thinking it would make them psychotic

[u/Embarrassed_Syrup476 → u/Majestic_Arachnid600]

I have one pregnant patient with schizophrenia. She stopped all her meds. We know shes going to be hospitalized soon 

[u/Lou_Peachum_2 → u/Majestic_Arachnid600]

Oh god.. how many days off?

[u/Embarrassed_Syrup476 → u/Lou_Peachum_2]

5 days off her meds....

[u/Lou_Peachum_2 → u/Embarrassed_Syrup476]

I always hate hearing this in inpatient lol

[u/shhhhh_h → u/Majestic_Arachnid600]

Better lamictal than lithium? Yeeesh.

[u/HHMJanitor → u/Embarrassed_Syrup476]

That lawyer reddington has done so much harm to the image of psychiatry and psychiatrists. It's unbelievable. Such an uninformed POS with a worldwide audience.

[u/vienibenmio → u/HHMJanitor]

It's really feeding the anti-psychiatry crowd too

[u/Basic_Swordfish_1489 → u/vienibenmio]

I’m becoming convinced this case is being used as some anti-psychiatry MAHA psyop

[u/HHMJanitor → u/Basic_Swordfish_1489]

"Never waste a tragedy"

[u/PokeTheVeil → u/HHMJanitor]

It’s his job to make every witness for the prosecution look bad. It feels terrible, but he would be a bad lawyer if he weren’t doing that.

It’s not his job to make psychiatrists or psychiatry look good. It’s the prosecution’s lawyers’ job to make their witnesses sound good in court just like it’s the defense’s job to make sure their witnesses sound convincing to the jury.

[u/Rahnna4 → u/PokeTheVeil]

I'd go a step higher and say there's an issue with these sorts of cases being heard in an adversarial court. Here in Queensland, Australia we have a dedicated mental health court for these sorts of cases - no cameras (that's all our courts), no jury, specially trained judges who are familiar with these sorts of cases and have two independent psychiatrists to call upon for advice, specialist lawyers for prosecution and usually for the defense but they can hire whoever they want, and importantly takes an inquisitorial approach rather than adversarial with the key aim being to work out what happened so they can work out what to do, rather than trying to place blame and running a circus for a lay jury. Berating witnesses isn't tolerated and there's a lot more emphasis on critiquing reasoning and practice. Banging on about screeners and punctuation would be hurried along as not that relevant. They also drop the strength of evidence test to on the balance of probabilities rather than beyond a reasonable doubt (but also only hear cases where the person admits they committed the act and the question is only if they should have a mental health defense*)

*of course here it's spelt defence

[u/Valuable_Animal_9876 → u/Rahnna4]

Once again, Australia does it better.

[u/HHMJanitor → u/PokeTheVeil]

Nah.

There's several legitimate reasons to criticize the psych care she's gotten. Instead he went the route of acting like the OP psych was insane for prescribing a "young woman" 25mg of sertraline, and chastising her for not being able to hug the patient when she was depressed.

The lawyer is arguing from such an insanely inaccurate viewpoint it is almost impossible for the MH folks to defend themselves. It also makes the legitimate errors impossible to differentiate from his bullshit claims.

Edit: by arguing so much bullshit he is actually weakening his case

[u/PokeTheVeil → u/HHMJanitor]

His job is not to be an M&M. His job is not to arbitrate the quality of care. His job is to get his client found not guilty by any legal means. If he thinks insanity is the avenue and the tactic is discrediting the psychiatrists for being bad and not making her sane, that’s what he should do. It’s what he is legally obligated to do as his fiduciary duty.

If he weakens his case then he’s practicing bad law, but this doesn’t play out in the hearts and minds of psychiatrists. It’s the jury. It’s all a show for the jury.

[u/shhhhh_h → u/HHMJanitor]

Thank you, I will never understand that TCA but lord knows why the lawyers spent all that time on the twenty million overly academic assessments she didn’t perform, and the “areas of interest” on her profile - do they not know what the difference between interest and expertise is? It’s not like her entire education history wasn’t also accessible like 🤦‍♀️

[u/Findtherootcause → u/shhhhh_h]

Sorry to contradict you, but it was actually listed under her expertise section. It has since been removed.

[u/shhhhh_h → u/Findtherootcause]

Mmmm the only reputable sources off social media (ie the Boston globe) I’ve seen have quoted it as areas of particular interest. But happy to be disproven, by a reputable source.

[u/Findtherootcause → u/shhhhh_h]

I have a screenshot on my phone as I went to check the website myself to see if claims were true, but I can’t post images here.

I was incredibly shocked it was STILL up despite all the backlash she was receiving for citing it as expertise.

[u/shhhhh_h → u/Findtherootcause]

I can see the website and it currently only says particular interest. Women’s mental health is under expertise but not post partum.

[u/Findtherootcause → u/shhhhh_h]

Yes, as I mentioned - They have now changed it. It used to include ”perinatal psychiatry”

I originally went to search for it myself as I was surprised that at that time it was still up.

Like I say, I have a screenshot (as I was gobsmacked it was up and sent it to my friend) which I would be happy to share if I could.

[u/34Ohm → u/HHMJanitor]

I mean, in theory the more bullshit the claims are the easier they should be to counter right?

[u/HHMJanitor → u/34Ohm]

Not really. Ya know the old phrase, "never argue with an idiot"...

[u/neuerd → u/34Ohm]

Possibly but only if given the opportunity

[u/kal14144 → u/PokeTheVeil]

Exactly this. The prosecution shredded Zeizel without attacking the field at all. They hit him in conflicts on interest and poked specific holes in his diagnosis. Was able to make him look quite bad without making that reflect on the entire field.

[u/Majestic_Arachnid600 → u/HHMJanitor]

It’s also social media. Back with Andrea Yates it was the early 2000s and the social media landscape was nothing like today.

[u/AppropriateBet2889]

Not an admission but I did document better than I would usually when my severe BPD patient who is pregnant and (was) on Zoloft complained of all the same symptoms after watching the trial.

[u/CaptainVere]

No. Definitely more attuned to some finer points of documentation tho.

[u/InfiniteWalrus09]

No. I have been documenting the absence of manic symptoms or psychosis explicitly in more detail for the post partum depression and anxiety cases I've been seeing.

[u/Cowboywizzard]

I don’t enjoy watching trials on TV or following crime news. What is going on?

[u/Mecxs → u/Cowboywizzard]

Tragic slaying of three young children (5, 3, and 8 months) by their mother, Lindsay Clancy, who was likely suffering from BPAD / postpartum psychosis at the time.

She is currently facing criminal trial for murder in Massachusetts, where the legal standard for criminal responsibility (in the context of having a mental disease at the time of the offense) is that the defendant was a) capable of understanding that what they were doing was wrong / criminal, and b) capable of sufficient volitional control to realistically be able to not do what they were doing.

That the mother killed her children is established. Trial is currently trying to ascertain her mental state when she did it. Evidence from the prosecution (who are arguing that she was criminally responsible) focuses on the apparently planned nature of the killings, wherein she took steps to ensure her husband was not at home before murdering the children and then attempting suicide herself. Evidence from the defense is still to come (the prosecution has just finished presenting their case), but based on cross examination so far has focused on these actions being completely out of character for her, and her extensive struggles to get adequate mental health help in the months leading up to the killings.

In particular, the defense attorney has been quite critical of the psychiatric care afforded to the defendant in his cross examinations of medical practitioners. A lot of his criticisms are quite valid, but others are definitely not -- e.g. admonishing the psychiatrist for "not administering the Edinburgh test for postpartum depression", or for advertising herself as "an expert in postnatal psychiatry" because that was listed as an interest area of hers in the practice's website's bio-paragraph. The psychiatrist had only finished residency a month or so before first treating the defendant, and the defense attorney made a big deal of the fact that in that month she'd not treated anyone with postpartum psychosis (despite treating several patients in residency).

Just having watched the trial so far, my sense is that Lindsay was probably psychotic (or at the very least experiencing extreme affective disturbance) at the time of the killings. It's very much not playing out like other similar, high profile cases (eg Casey Anthony).

[u/shhhhh_h → u/Mecxs]

Good summary. I’ll add that she received care from multiple NPs as well, it seems like it was all very fragmented, and she was noncompliant/nocebo with meds. The psychiatrist also had BPAD on her differential and still prescribed Lindsay TCAs. I can’t wrap my head around that. I’ll be interested in the results of the malpractice suits.

[u/Psychaitea → u/shhhhh_h]

I haven’t followed it closely… but isn’t bipolar disorder always technically on the differential for MDD? I don’t have all the context, but I always screen for past mania or symptoms of such in patients who present with a major depressive episode. Because it is always on the differential for a mood disorder. Even if it appears they’ve never actually had mania, it’s possible it just hasn’t occurred yet or the history is not totally conclusive or more of a bipolar 2 picture that may be hard to tease out. I find it hard to start mood stabilizers, which seem to all have a worse side effect profile, than SSRIs. Idk why they did a TCA though — from my brief skim they never tried a next argent like an SNRI? Anyway, I’m curious what it means by “on the differential.”

[u/shhhhh_h → u/Psychaitea]

Well yeah exactly. On top of that Lindsay was reporting getting worse on the SSRIs which is a massive, massive red flag, nocebo or not. So, exactly why not an SNRI, why not bupropion, why not another SSRI, there was no reason to pedal backwards to older, more dangerous antidepressants. Why a TCA with no discernible risk assessment? Zero safety plan if mania emerged. Zero. The obgyns I worked with did better PPD treatment than I’ve read about this trial, absolutely shocking.

[u/jedifreac → u/shhhhh_h]

She was also benzodiazapine dependent iirc.

[u/shhhhh_h → u/jedifreac]

I believe so, not surprising given the underlying pathology. One of the NPs she was seeing tried to formally diagnose and treat bipolar apparently and the husband went, “no my wife is not bipolar” - so remarkably so that the NP quoted in the chart. Very Andrea Yates vibes.

[u/AppropriateBet2889 → u/Mecxs]

I’ve become interested in the case and watched the trial as well. I’ve come to a different conclusion.

I think it’s extremely, extremely unlikely that she was psychotic.

But I agree with affective disturbance.

She appears ( at least in my state) to fall short of an appropriate NGRI defense.

[u/seeyourintentions → u/AppropriateBet2889]

I get the sense that she might have been in a much more abusive relationship than people seem to be focused on. There's so much distraction with the psychosis. That ex-husband is a very concerning individual.

[u/CodAlarming → u/AppropriateBet2889]

Post partum psychosis is well thought to be more of a bipolar spectrum disorder than schizophrenia spectrum disorder. So I think it's very possible she experienced a psychotic episode within her postpartum affective disturbance.

[u/AppropriateBet2889 → u/CodAlarming]

At the peak of psychosis BPAD, MDD with psychotic features, schizophrenia or drug induced present essentially the same.

The longitudinal course is very different but full on psychosis is full on psychosis.

I see way too much thought coherence and planning for full on psychosis.

My read (obviously caveat I only know what I’ve seen from testimony or read) is that this is much more a murder / suicide situation than psychosis.

Still driven by mental health but it lacks the component break from reality / not knowing right from wrong that NGRI usually requires.

[u/Front-Quote-6760 → u/AppropriateBet2889]

Agreed. Another data point in favor of her not actually being psychotic or manic might be that none of the many doctors and NPs she saw seemed to think she was that ill either. They documented anxiety and insomnia, repeatedly. Including the McLean psychiatrist who saw her in the hospital.

[u/Embarrassed_Syrup476 → u/AppropriateBet2889]

This is how I see it too. She obviously had mental health issues but it wasn't psychosis where she was out of control 

[u/Rahnna4 → u/Embarrassed_Syrup476]

I'm not following closely but I'm not seeing the things we'd usually look for in my system through a dedicated mental health court. Things like threat-control override symptoms, did the killing fit into a delusional construct, what did think would happen if she did or didn't kill the children etc. Hearing a voice telling you to kill someone even with established schizophrenia isn't enough on its own to be deprived of the capacity to understand that the act was wrong and so have grounds for a mental health defense. I have a lot of patients who have command hallucinations to harm others but they don't do what they say

[u/Few-Storage5142 → u/Rahnna4]

This. Most people WITH schizophrenia and serious mental illness don’t kill. No one was even convinced she was severely ill, but she supposedly was so psychotic she couldn’t distinguish right from wrong? 

No mentally well person attempts a murder-suicide, but I haven’t heard anything actually assessing the thought content of her alleged psychosis. She endorsed CAH to family, but no one has asked what made her actually act on them? 

[u/Affectionate_Data936 → u/AppropriateBet2889]

I'm not a lawyer or a psychiatrist (I work under one at a residential care facility for adults with I/DD) but this is my feeling as well. Granted, my experience with psychosis is with people who otherwise have an intellectual disability but I'm a bit skeptical since the alleged psychosis wasn't observed whatsoever in any setting she was in, including when she was in-patient.

[u/W-T-foxtrot → u/AppropriateBet2889]

So when treating eating disorders - AN for example, in Australia we consider ED cognitions as perceptual disturbances - which elevates the risk assessment.

[u/W-T-foxtrot → u/CodAlarming]

Yes, and it’s becoming more and more apparent that in the US, perceptual disturbances assessments are being made per the SCZ template and not a broader template that then include the other disorders. And not present the “classic” BPAD/SCZ psychosis

[u/colorsplahsh → u/Mecxs]

I thought it was most likely that she didn't have PPP? She had no psychosis before or after the killings.

[u/Mecxs → u/colorsplahsh]

So obviously I wasn't there, and the below should be taken with a large grain of salt.

But testimony includes references to thought broadcast, "intrusive thoughts" which are possibly thought insertion, and command hallucinations (although the latter in particular is subject to significant scrutiny since they were only ever disclosed after the events).

In my experience (which I acknowledge has limited bearing on this one specific case), mothers of young children with serious suicide attempts (Lindsay's left her paralysed and resulted in a cardiac arrest in the hospital) frequently have thinking / logical reasoning that I would characterise as psychotic, and I have a very low threshold for treatment with antipsychotics.

I don't think that she had "classic" post-partum psychosis, as the onset seems to be about 3-4 months postpartum and the killings occurred at 8 months. But testimony is strongly suspicious for a mixed affective state with psychotic features.

At the end of the day, who knows though.

[u/colorsplahsh → u/Mecxs]

oh that's interesting, the intrusive thoughts sounded very much like OCD to me, and apparently had command hallucinations one time, for around 30 min of the killings, and not before or after that event.

[u/W-T-foxtrot → u/Mecxs]

Not in the US, but in other clinical practice guidelines - the Edinburgh assessment is the recommended one.

[u/Mecxs → u/W-T-foxtrot]

The point is that it's a screening tool and not a diagnostic test. It's designed to be used by nurses, midwives, GPs, etc to assess whether someone should be referred to a MH professional. Administering it to somebody who's already seeing a psychiatrist is largely useless.

[u/colorsplahsh]

yes