The lawyer for Lindsay Clancy, the Duxbury mother who allegedly strangled her three young children, said regardless of whether his client suffered postpartum depression or postpartum psychosis one thing was clear: His client was overmedicated with 13 different drugs over four months.
The result, attorney Kevin Reddington argued, was a “horrific overmedication of drugs that caused homicidal ideation, suicidal ideation.”
Specialists who treat women with these mood disorders say it’s not uncommon for providers to try multiple medications, either simultaneously or if others are found to be ineffective. Yet, some said that using more than a dozen such drugs in such a short span of time is unusual.
Among the medications listed by Reddington are three benzodiazepines — Klonopin (clonazepam), Valium (diazepam), and Ativan (Lorazepam) — typically used to treat anxiety and insomnia.
Others are for mood disorders, including Zoloft, amitriptyline, Remeron (mirtazapine), and Prozac (fluoxetine), all used to treat depression and anxiety. Zoloft, and Prozac are in a class of drugs called SSRIs, or selective serotonin reuptake inhibitors. Trazodone (often used in small doses for insomnia) is in a subclass of SSRIs called serotonin receptor antagonists and reuptake inhibitors, or SARIs.
Clancy was also prescribed mood stabilizers Lamictal (lamotrigine) and Seroquel (quetiapine fumarate), which can be used to treat and prevent mania and depression. Her attorney also listed buspirone (an antianxiety drug), hydroxyzine (an antihistamine that is traditionally used for anxiety or insomina), and Ambien (a sedative-hypnotic).
Dr. Nancy Byatt, a psychiatry professor at UMass Chan Medical School who often treats women with postpartum mood disorders, would not comment specifically on Clancy’s case or her medications. But she said she tries to use benzodiazepines only sparingly because of the risk that a patient builds up a tolerance to the medication and it becomes less effective.
“If someone is in a situation where they need a lot of medications to get by, then you want them to be assessed to see if [they] should be hospitalized,” she said.
It is unclear which medications Clancy was taking simultaneously, at what doses, and who prescribed them. Reddington told reporters Friday she was being treated by a “number of psychiatrists,” and that “there is no doubt she was overmedicated,” but declined to say where she received her treatment.
Dr. Jessica Pineda, an assistant professor in psychiatry and human behavior at Brown University’s medical school, said that in her experience, it is “not typical” to prescribe more than a dozen different medications over a four-month span.
”There are situations in which individuals are not responding so we are using different medicines to see if something may work better, while trying to limit the number of medicines an individual is on at any one time,” she said.
Many experts said the first-line approach to postpartum mood disorders is therapy. Depending on the extent of a woman’s illness and capacity to care for herself and her child, medication might also be considered.
But getting into therapy can itself be an ordeal. Many mental health counselors have long waitlists, worsened by larger numbers of people experiencing anxiety and depression during the pandemic. Medication may be used as a bridge to therapy, said Jill Fieleke, a board certified psychiatric nurse practitioner, who offers care primarily to pregnant and postpartum women.
Prescribing practices vary based on what the mother may need. It is not uncommon for sleep to be disrupted, and a sleeping aid is often an initial tool. SSRIs, a class of antidepressants, are also commonly used for both mood and anxiety disorders in the postpartum period.
Fieleke said it was not uncommon for someone to be prescribed more than one medication at the same time, or over a period of time, though she declined to comment on Clancy’s case. A medication that might help a person’s depression might not help with their sleep, or work fast enough to help them sleep in a timely manner. It is also not unusual for a provider to try several short-acting medications, especially if one is not working and the patient’s situation is deteriorating.
“Many women postpartum a variety of symptoms — some insomnia, some anxiety, some depression symptoms. It’s not uncommon to prescribe more than one medication for someone in the postpartum period because they each act in different ways,” Fieleke said.
Reddington, the attorney, noted that the SSRIs Clancy was prescribed have a so-called black box warning. These warn patients the drugs can in rare instances cause the onset of suicidal ideation, though primarily the risk is in adolescents and children, experts noted.
“The husband actually went to the doctor the week before and asked for help and said, ‘Look, it’s turning her into a zombie.’ It was a brutal, brutal resistance,” Reddington said.
One physician, Dr. Leena Mittal, said people with a mood disorder are at greater risk of suicidal ideation from the condition itself rather than as a side effect of medication used to treat it.
Sometimes people can experience emotional symptoms as they stop certain medications, but they tend to be mild, and suicidal ideation from stopping medication is also rare.
“Harm to others is an extremely rare event when associated with psychiatric illness or treatment,” said Mittal, a medical director at MCPAP for Moms, which provides aid and psychiatric consultation to pregnant and postpartum women, and also heads the women’s mental health unit at Brigham and Women’s Hospital.
While providers often want a patient to be taking the fewest number of effective medications possible, approaches to postpartum mood disorders are nuanced and vary from one individual to the next. Given that complexity, it is hard to draw any conclusions from a list of medications, Mittal said. What matters more is what a patient is taking, for how long, how they respond, and what symptoms remain after a trial.
“It’s a process of adjustment and waiting and assessing and monitoring that requires time, sometimes frequent visits. And also sometimes people will be on multiple medications,” Mittal said.
Multiple experts noted that many women who suffer from postpartum mood disorders don’t get treated at all.
Some expectant and new parents express hesitation about using powerful antidepressants or other medications for fear they may harm the fetus or breastfeeding baby. But Pineda said most often the benefits of using such medications outweigh the risks.
“We are balancing the risk of what happens if we don’t treat this with what we know from the data,” she said. ”We have information ... that postpartum symptoms impact child development, including academic achievement and child behavior. The goal is to have a healthy mother and child.”
This story has been updated to reflect that trazodone is in a subclass of SSRIs called serotonin receptor antagonists and reuptake inhibitors, or SARIs.
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