Arguably the most hotly debated result in a murder trial anywhere in the world, the Lindsay Clancy case pits angry mobs calling for her guilt against those who agree with DR SALLY SATEL, a psychiatrist and lecturer at the Yale School of Medicine, who was hoping for an acquittal and commitment to a mental facility because, in her clinical opinion, psychosis drove Clancy to kill. She explains why, in this article published in The Free Press, where it attracted nearly 1700 comments.
The trial of Lindsay Marie Clancy is over, and unresolved. After 21 days of testimony and seven days of deliberation, a Massachusetts jury could not agree on whether the 36-year-old former nurse was criminally responsible for strangling her children—Cora, 5; Dawson, 3; and Callan, 8 months—or not guilty by reason of insanity. The judge declared a mistrial.
I had been hoping for an acquittal and commitment to a mental facility because, in my clinical opinion as a psychiatrist, psychosis drove Clancy to kill.
The prosecution now has the option of bringing an entirely new trial, negotiating a plea deal, or dismissing the charges altogether.
Clancy continues to be charged with three counts of first-degree murder. Her lawyer and the prosecutors will consider next steps while she remains in a mental-health facility.
Whatever comes next, the case is a reminder about the hazards of addressing mental illness challenges in the courtroom, the need for legal and psychiatric reforms, and the urgency of educating doctors as well as patients about psychosis in general and postpartum psychosis in particular. If Clancy is retried, here is why I hope the next jury will find her not criminally responsible.
On January 24, 2023, Clancy took her children, one by one, into the basement of the family’s home in Duxbury, Massachusetts. “Go to God, baby,” she allegedly said as she asphyxiated each of them with exercise bands. She then made cuts on her wrists and neck, and jumped out of a second-story window in a suicide attempt that left her paralysed below the waist. She did these things during the hour it took her husband to complete an errand she asked him to run.
The tragedy was the culmination of five months of anguish and help-seeking. Although Clancy said she initially felt well following Callan’s birth in May 2022, she saw a psychiatrist in late summer for help with depression, severe insomnia, and feelings of being overwhelmed by simple tasks like dressing or showering.
Over time, she allegedly began having suicidal ideation and experiencing what have been variously described as “intrusive thoughts” and “auditory hallucinations” telling her that she was “damaged” and would “not be the same,” and that “the only option is to die.” In December 2022, she told her husband and mother that she had thoughts of harming her children and was worried that other people could hear those thoughts.
After Clancy’s husband left to pick up food and medication on January 24, 2023, she said that a loud, demanding male voice told her over and over, “This is your last chance. You have to kill the kids so you can kill yourself.” She allegedly entered “a dreamlike state” and watched herself act, feeling as if she had “no choice.” A hospital chaplain who met with Clancy within weeks of the crime testified that Clancy said the voice “told her that if she did not follow the command, neither she nor her children would be safe.”
From September 2022 to January 2023, Clancy received several formal diagnoses: adjustment disorder and generalized anxiety disorder at the Aster Mental Health clinic, and major depressive disorder at McLean Hospital. A psychiatric nurse practitioner raised the possibility of postpartum depression before the killings, though it was never formally diagnosed, and Clancy’s bipolar disorder and PTSD were not fully diagnosed until afterward.
Why so many different diagnoses? And why might postpartum psychosis have been missed until after the killings? Unlike postpartum depression, a relatively common diagnosis that occurs in one out of eight deliveries, postpartum psychosis is rare, occurring just once or twice in every 1,000 deliveries.
Clancy’s situation was also not textbook postpartum psychosis. She did not have symptoms for three months after Callan’s birth, although, according to the DSM-5, postpartum psychosis manifests rapidly within the first month after delivery. Also, expert witnesses at her trial debated whether Clancy suffered actual psychotic episodes before the killing and whether the voice she heard in her basement on January 24 was a true command hallucination or merely an insistent internal thought that she chose to obey.
Whatever comes next, the case is a reminder about the hazards of addressing mental illness challenges in the courtroom.
Also, Clancy did not consistently report suicidal or homicidal thinking or hallucinations to clinicians, perhaps because her mood and ideation fluctuated over the course of the day—a standard feature of postpartum psychosis.
She might also have been afraid that a clinician would call child protective services and her children would be taken away. Or she might have worried about being committed to a psych ward, thereby putting her nursing license in jeopardy, a common concern among struggling health professionals.
Diagnosing after the fact is a tricky business. Even so, as the defense said, Clancy’s clinicians should have known that she had experienced boundless energy, racing thoughts, obsessive cleaning, and feelings of elation—a manic state—in the weeks after her son Dawson was born in 2019. Talking to her husband or parents or ob-gyn at the time could provide such data if the patient is not forthcoming. Importantly, a history of postpartum activation or mania is a risk for full-blown postpartum psychosis after the birth of subsequent children.
Clancy’s pharmacological treatment also came in for intense scrutiny by the defense. In all, she received mental-health care from at least six clinicians, who prescribed a total of 13 drugs, including antidepressants, antipsychotics, mood stabilizers, and benzodiazepines (drugs in the Valium family).
Some of these medications exacerbated her already serious condition. Clancy’s first antidepressant, Zoloft, which she tried in the fall of 2022, triggered racing thoughts and a two-day period of no sleep—another suggestion of a bipolar disposition. Also, Zoloft’s strong activating effect on her suggests a potential for bipolar disorder. The antipsychotic drug Seroquel may have caused akathisia (a highly disturbing inability to remain physically still).
What’s more, prolonged lack of sleep is a well-known precipitant of mood changes, intrusive thoughts, hallucinations, and disinhibition. Another glaring problem: No single clinician was coordinating and monitoring her care and medications. One clinician prescribed three new medications in one day—typically a risky move because it’s impossible to tell which one might be responsible for a bad reaction if one occurs.
Hindsight is clear-eyed, and I am a bit hesitant to criticize her clinicians, who truly seemed to want to help. That said, someone in charge needed to know if Clancy’s condition was resistant to the medications (her illness just was not responding) and if her medications caused intolerable side effects. This is difficult to do without knowledge of all the treatments she received; after all, clinicians need to know whether it might have been time to move to lithium or even electroshock. Escalating treatment is warranted because, if postpartum psychosis is treated well, the patient has an excellent chance of getting better.
My last point about prognosis is important because some experts are now worried that the media coverage, as well as civil malpractice actions filed by Clancy and her husband, are making clinicians reluctant to treat high-risk patients. They need to keep in mind, however, that the vast majority of women with postpartum psychosis do not commit filicide like Lindsay Clancy, and that, as I indicated, not only is postpartum psychosis rare, the response to treatment is usually good/
Massachusetts uses the McHoul standard for insanity. It allows for a determination of “not criminally responsible” if a person with a mental disorder or defect (which every expert agreed Clancy had) lacks either the capacity to appreciate the wrongfulness of her conduct or the capacity to conform her conduct to the requirements of the law. If the defendant presents evidence to support her lack of responsibility, the prosecutors bear the burden to prove her responsibility beyond a reasonable doubt. Some thought the prosecutors did not carry this burden; others thought they did.
I see particularly strong reasons to doubt Clancy’s capacity to conform her behavior to the demands of the law. After her husband left on the errand, she experienced an audible command to kill. She felt she had to “obey,” according to psychiatrist Phillip Resnick, an expert for the defence. Resnick also testified that Clancy suffered a “delusion of influence” (a formal term) just before and during the killing. “She felt that her body was taken over by an external force, where she was in a dream state and did not have control of her own body,” Resnick told the jury. “It was almost like she was a puppet and someone else was pulling the strings.” In short, this compulsion made it impossible for her to follow the law.
I could also make a case for solid skepticism that Clancy appreciated the wrongfulness of her conduct. This does not mean that she was ignorant of the law—she surely knew that murder was wrong and illegal. Rather, it means that she was acting on a deranged belief that her kids would suffer so greatly without her that they needed to die. Clancy genuinely believed, Resnick said, that she was protecting the children by taking them with her to heaven. Consistent with this formulation was Clancy saying to a hospital chaplain a week after the killings: “I am so glad my children are safe.”
In reaching these conclusions, I have accepted the truth of Clancy’s description of the voice she heard and her explanation of why she followed its command. I believe her account because absolutely nothing in her past foreshadowed her cataclysmic act. She was uniformly regarded by family members, friends, and her nanny as an excellent mother and a caring, sensitive woman.
She had no history of aggression, child abuse, or violence—apparently, she had never even spanked her kids. Nor is there an alternative explanation outside of psychosis: Clancy did not want to be rid of her children to be with another man, nor was she punishing her husband. (emphasis added)
I understand why so many think Lindsay Clancy is a monster. Psychosis is alien and its all-consuming power is difficult to grasp. I can see why some people turn to punishment as the resolution of an unfathomable crime and as justice for the children.
I’d hoped the jury would unanimously blame the ravages of a terrible illness, rather than the woman at the center of this tragedy. In the end, it was stymied.
Three lives have been ended and many others have been irreparably damaged. Yet some good might come from this highly publicized trial. For one, the American Psychiatric Association could revise the DSM to include a separate section dedicated to postpartum mental disorders, and to designate postpartum psychosis as a discrete diagnosis produced by hormonal fluctuations and sleep deprivation, and correlated with a history of bipolar disorder-like symptoms. Its inclusion would help ensure that the diagnosis would be taught in medical school and residency programs.
the death of a child at the hands of an otherwise loving mother is one of the most profound aberrations of nature there is.
Professionals that typically see women soon after birth and then for checkups within a few weeks of giving birth, such as paediatricians, ob-gyns, doulas, and midwives, should also be educated about the symptoms of postpartum psychosis. They should think of the postpartum period more expansively, and not as limited to the four weeks after delivery. Families, too, should be informed about this risk to maternal mental health.
If women need to be hospitalized, they should be able to take the baby with them. In addition to allowing for integrated care, this practice could help researchers make valuable observations on the best way to ease the connection between mother and child.
Early clinical intervention is always the optimal response, but when the clinical guardrails give way, the legal arena is where the major decisions about the offender’s fate are made. Efforts to create a stand-alone maternal infanticide law, which recognizes postpartum mental illness as a mitigating factor, is worth considering. Though imperfect—it still punishes women whose mental illness made them kill—at least such a law recognizes that the death of a child at the hands of an otherwise loving mother is one of the most profound aberrations of nature there is.
# For another perspective, see our report ‘Who are really responsible’