Brief Treatment and Crisis Intervention Advance Access originally published online on July 17, 2007
Brief Treatment and Crisis Intervention 2007 7(3):239-247; doi:10.1093/brief-treatment/mhm006
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Postpartum Mood Disorders: When Mothers Kill—The Case of Mary Ellen Moffitt
From The Southwest Council, Inc., Vineland, NJ, 08360
Contact author: Lauren Radano, Prevention Specialist, The Southwest Council, Inc., Vineland, NJ. E-mail address: Lradano{at}gmail.com.
This article provides a detailed case study of Mary Ellen Moffitt, a mother suffering from postpartum depression, who killed her 5-week-old daughter and then committed suicide. Similar cases have been widely publicized in recent years and deserve increased attention. The notion that postpartum depression is strictly a biological disease is inaccurate, as there are typically psychosocial factors that contribute to the disease as well. The final section of this article examines treatment options.
KEY WORDS: postpartum depression, depression, Mary Ellen Moffitt, infanticide
Mary Ellen Moffitt was the picture-perfect housewife. Filling her Michigan home with inspirational quotes and smiling family photos, Mary Ellen kept a tidy, two-story brick home decorated with bright flowers. The house was just across the street from the Catholic Church where she and her family attended Mass every Sunday. Voted Teacher of the Year for the East Detroit Public School System, Mary Ellen was known for her affection for children. Every day, she opened her arms to hug each first-grader who arrived to her classroom and she looked forward to having children of her own. Her friend Aylex Araque, mother of two, remembers her saying, "You don't know how lucky you are. We've been trying so hard [to have a child]." (Capeleto, 2004) Clearly, she was the last person anyone thought capable of harming a baby. However, on one tragic day in 2004, her husband Daniel Moffitt endured what may be becoming every new father's worst nightmare. His wife had killed their 5-week-old daughter Caroline and then killed herself (Capeleto & Walsh-Sarnecki, 2004).
According to reports, Daniel had arrived home to find Mary Ellen dead on the couple's bed with a garbage bag and scarf tied around her head. He was not able to find Caroline until 911 responders notified him that she was on the living room couch, tightly wrapped in a blanket and dead of asphyxiation. Indeed, Mary Ellen had been suffering from postpartum depression and was seeking treatment. Those closest to her though say there were no outward signs of her distress (Capeleto & Walsh-Sarnecki, 2004). A friend remembers her as "a very upbeat person, had a marvelous smile [and was] just the kind of gal you could always approach" (Capeleto & Walsh-Sarnecki, 2004).
Often, the symptoms of postpartum mood disorders are not explicit and people are shocked when a mother kills her own child(ren). The news is abundant with stories of mothers who kill and then leave their babies in trashcans or dark alleys for someone to find. Public concern has grown so immense in the past 5 years that 46 states now have a protective law for unwanted babies, entitled the Safe Haven Act (Adame, 2005). According to the Massachusetts Safe Haven Act (Baby Safe Haven, 2004), "parents may legally surrender newborn infants 7 days old or younger at a hospital, police station, or manned fire station without facing criminal prosecution." If there are no signs of abuse or neglect to the newborn, then no legal action will be initiated against the parents. After the Department of Social Services (DSS) is notified, they will take the baby into custody and place it in a DSS-approved preadoptive home (Massachusetts Safe Haven Act of 2004).
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Infanticide |
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Sadly, many mothers still do not use this service and abandon their babies at random bus stops and in public bathrooms to die. The U.S. Bureau of Justice Statistics (2004) defines the homicide of a child under the age of 5 as infanticide and the practice is actually quite common throughout the world. For example, in many non-Western cultures, infanticide is used as a method of population control (Research Machines, 2005). In hunter-gatherer and nomadic societies where it may be impossible for a mother to carry around more than one small child and still perform the tasks necessary for survival, killing a child is typical. In India and China, boys are valued more than girls, so if a baby is born female, she is more likely to be killed. In fact, it is estimated that over 1 million babies are murdered every year because they are born female (Research Machines, 2005). Finally, "infanticide may also be practiced on deformed or sick infants or for religious or ritual purposes; in some African societies twin births are thought to be supernatural and the twins are left to die" (Research Machines, 2005).
In American culture, "while the incidence of infanticide has increased [between 1976–2002], the rates have remained fairly stable" (U.S. Bureau of Justice Statistics, 2004). Still, between these same years, a parent has been the killer more often than not. In all cases, 31% of infanticides were committed by fathers and 30% were committed by mothers (U.S. Bureau of Justice Statistics, 2004).
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Infamous Cases |
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After recalling the most popular cases in America, the severity involved is what appears to have grabbed media attention the most. For example, Andrea Yates was a mother from Texas who did not kill just one of her children, but drowned all five in the family's bathtub. Susan Smith was another mother who drove her family's car into a lake near her home with her two little boys inside and then pleaded on national television with a supposed kidnapper who she alleged had taken her boys. Finally, actress Brooke Shields recently admitted to suffering from severe postpartum depression and of not being able to avoid the image of her newborn daughter flying through the air and hitting the wall in front of her (Shields, 2005).
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What Is Postpartum Depression? |
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To understand postpartum mood disorders, one must first recognize that up to 85% of women experience some type of mood disturbance postpartum (Nonacs, 2004). According to Dr. Ruta Nonacs (2004), "for most women, symptoms are transient and relatively mild (i.e., postpartum blues); however, 10–15% of women experience a more disabling and persistent form of mood disturbance (i.e., postpartum depression, postpartum psychosis)." Originally, postpartum psychiatric illness was viewed as a group of disorders related specifically to pregnancy and childbirth. However, in recent years, scientists have learned that postpartum psychiatric illness is basically indistinguishable from psychiatric disorders that occur at other times during a woman's life. Therefore, caregivers find it difficult to determine the cause and effects of a woman's depressive symptoms after childbirth. Leaving these symptoms untreated places both the mother and child in danger and can have long-term developmental effects on the child (Nonacs, 2004).
The mildest form of postpartum mood disorders is postpartum blues. Symptoms of this include "rapidly fluctuating mood, tearfulness, irritability, and anxiety" (Nonacs, 2004). These symptoms peak on the fourth or fifth day after delivery and can last for several days. Fortunately, they are known to spontaneously remit within 2 weeks and do not interfere with the mother's ability to function and care for her child (Nonacs, 2004).
Postpartum depression is the next highest level of postpartum mood disorders and affects between 10% and 15% of women. Those who have a personal history of depression or a previous episode of postpartum depression are at highest risk (Nonacs, 2004). Usually, this form of depression develops over the first 3 months after delivery and symptoms may include "depressed mood, tearfulness, anhedonia, insomnia, fatigue, appetite disturbance, suicidal thoughts, and recurrent thoughts of death" (Nonacs, 2004). Anxiety is prominent and the mother constantly worries about the infant's health and well-being. Ironically, the mother may have ambivalent or negative feelings toward the infant as well. Those with a more severe form of postpartum depression may even have thoughts of harming the infant, but find the thoughts intrusive and unpleasant. Overall, postpartum depression can be drastically debilitating and greatly interfere with the mother's ability to care for her child properly (Nonacs, 2004).
Finally, the worst form of postpartum mood disorders is postpartum psychosis. Fortunately, this type is rare and occurs only in one or two mothers out of every 1,000. Women with bipolar disorder are at highest risk. Postpartum psychosis has a dramatic onset and can be observed as early as the first 48–72 hr after childbirth (Nonacs, 2004). Within the first 2 weeks, a mother can experience rapidly evolving manic or mixed episodes "with symptoms such as restlessness and insomnia, irritability, rapidly shifting depressed or elated mood, and disorganized behavior" (Nonacs, 2004). The scariest part is that the mother may also have "delusional beliefs that relate to the infant (e.g., the baby is defective or dying, infant is Satan or God), or she may have auditory hallucinations that instruct her to harm herself or her infant" (Nonacs, 2004). Risks for infanticide and suicide are highest among these women if this psychosis is left untreated (Nonacs, 2004).
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Psychosocial Factors |
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In this way, many are left to wonder, "what makes a mother so distressed that she would kill her baby and/or herself?" The truth of the matter is that having a baby may be considered a Level Two or Level Three on a stress–crisis continuum according to definition (Burgess & Roberts, 2005). For instance, the stress–crisis continuum has five different levels, with each increasing in intensity as well as number. Level Two is considered "transitional stress" and may be associated with a "disruption of developmental life passage, altered self-regulatory pattern, or [an] identified psychological issue" (Burgess & Roberts, 2005). Examples can include divorce, loss of employment, or birth complications. These exact complications, although not stated explicitly, could most likely range from medical complications to relationship or spousal complications before, during, or after the pregnancy. The next level, Level Three, is defined as "experiencing, learning of, or witnessing a sudden, unexpected stressor" (Burgess & Roberts, 2005). Certainly, if a pregnancy is unexpected or unwanted, it may be viewed as a Level Three type of stress. Treatments for these different levels of trauma and stress will be discussed later.
Regardless, people still struggle to grasp the paradox associated with postpartum depression and the fact that so many mothers have the potential to be afflicted. Often, being a new mother is equated with joy, happiness, and family development, and if the mother is not experiencing an outward level of stress on the aforementioned continuum, then what goes wrong? Unfortunately, the darker side to mothering is not a side that many want to see, but it is there. Along with motherhood comes sleepless nights, loss of autonomy, possible relationship strains, and possible financial strains just to name a few. Even Mary Ellen Moffitt is noted to have called a friend who had also recently given birth and asked, "What are we doing? Did we mess up our lives?" (Capeleto, 2004) Having a baby changes a woman's life in more ways than one and the effects can be troublesome.
Indeed, females "are happy to be mothers to their children, while unhappy at the losses that early motherhood inflicts upon their lives—losses of autonomy and time, appearance, femininity and sexuality, and occupational identity" (Nicolson, 1999, p. 162). Although being a mother is certainly no longer the only identity a woman can achieve, it still constitutes a large part. Indeed, motherhood changes women's lives no matter how much they identify with it. For example, a mother's life changes socially, emotionally, and economically whether she plans it or not. Some low-income, poorly educated young women even see it as their means of liberation from boring paid employment and do not have a realistic concept of the stress involved in raising children (Nicolson, 1999).
Nicolson (1999) also discusses the image of motherhood as a mythical and powerful role. In fact, research suggests that motherhood is frequently a job of selflessness and sacrifice. "Women experience the pleasure and pain of caring for others, giving and receiving love alongside social isolation and the resentment that they are no longer able (or even sometimes willing) to put themselves first" (Nicolson, 1999, p. 163). Certainly, even within a home, a woman's power can also conflict with a man who spends most of his time working outside the home.
Yet, despite all these potential problems, becoming a mother is still expected to be an entirely happy event. This may be because the one thing missing in most of the research is accounts from the mothers themselves. Unfortunately, many scientists still claim that postpartum depression is exclusively biological and develops as a result of hormonal imbalances both during and after childbirth. (Nicolson, 1999) Although biological factors may contribute to postpartum depression, ignoring social and emotional causes is a disservice to mothers.
Research by Nicolson (1999) suggests that:
socially isolated women from low socioeconomic status backgrounds, who live in poor housing and have marital difficulties are more likely to experience depression at this stage than women who have good social support networks and are from affluent backgrounds. (p. 163)
Psychological background, personality factors, and the experience of childbirth also play a part in a woman's susceptibility to postpartum depression (Nicolson, 1999). For example, one woman's personality may be more career-oriented and driven, and she may view being a stay-at-home mom as inferior to having a career outside the home. One mother that Nicolson (1999) interviewed states, "When the money in the purse is mine—I'd just go and do it [buy the baby a new cot]. But because I have to ask him for the money I don't like doing that ... I feel I'm not contributing to the finances" (p. 170). Indeed, a wife's loss of financial freedom is sometimes a source of conflict within a marriage. Finally, physical exhaustion following childbirth and bringing the infant home is thought to contribute to postpartum depression as well. Nicolson (1999) believes that if these struggles were recognized as important and holding validity, reintegration and respect from society would be much easier to achieve for these women.
Another major factor that may contribute to postpartum mood disorders is the perception of both parents of whether the pregnancy was intentional or wanted. According to Leathers and Kelley (2000), "unintended pregnancies result from complex, multi-dimensional aspects of behavior, including conflicting desires within relationships and individuals" (p. 523). In Mary Ellen's case, she and Daniel had tried to conceive for the entire duration of their 12-year marriage, to no avail (Caruso, 2004). This difficulty already placed Mary Ellen at higher risk for postpartum depression, according to Dr. Ronald Rosenberg, who states that those "who have grappled with infertility can be more vulnerable to postpartum depression" (Capeleto, 2004). Although she and Daniel were elated with the news of Mary Ellen's pregnancy, the event may have subconsciously been unexpected after so many years of failure. Perhaps both partners, especially Mary Ellen, had already made peace with not having a child and were not prepared for Caroline's arrival.
Among married women in 1990, 37% had unintended their pregnancy, and there is little research focusing on its consequences (Leathers & Kelley, 2000). From the research that has been conducted on intention, women experiencing a pregnancy that is neither intended nor wanted (14% of all unintended pregnancies), rather than mistimed, are four times as likely to experience depression. Those who had a mistimed pregnancy were just two times as likely (Leathers & Kelley, 2000).
Interestingly, a woman's postpartum depressive symptoms were also significantly related to her partner's perception of whether the pregnancy was intended. Surely, an unintended pregnancy and the father's desire to have a child may cause great relationships distress and put a vital part of the woman's social support network at risk. According to the study of Leathers and Kelley (1999) of over 124 couples, women are at greatest risk for depressive symptoms when they may have intended the pregnancy and their partners did not. Although most couples agreed about whether their pregnancies were intended, 13.7% of women claimed it was intended, when the partner said it was mistimed or unwanted (Leathers & Kelley, 2000).
Furthermore, Leathers and Kelley (2000) also found that these same women reported fewer depressive symptoms during the postpartum period than during pregnancy, whereas men's report of such showed no significant change. During pregnancy, 7.3% and 30.6% of women reported scores of over 16 on the Beck Depression Inventory (indicative of major depression). Following childbirth, 6.5% of men and 11.3% of women reported scores of over 16 (Leathers & Kelley, 2000). This may suggest that depressive symptoms were highest during pregnancy due to anxiety and not knowing whether both partners should be excited about a baby just yet. By the time the baby is born, parents may have adjusted to the idea and may have made a commitment to being parents together.
Similarly, a study was conducted by Campbell and Cohn (1991) on 1,033 women who were expecting their first baby. The study found that 9% of women were diagnosed as having clinically significant depression during the first two postpartum months, so this figure supports the aforementioned 10% or so that are at risk. However, one major finding of this study is that "depression is not more common in postpartum women than in nonchildbearing women of similar age and demographics" (Campbell & Cohn, 1991, p. 596). The data also caution people to be aware of the difference between postpartum mood disorders and regular postpartum adjustment. In fact, nondepressed postpartum women in the study reported more somatic than cognitive or affective symptoms. In this way, there are certain expected adjustments that must be made by mothers. For instance, pregnancy and delivery complications, even rather minor ones, can contribute to feelings of sadness and distress in mothers. Additionally, other physiological changes of parturition and matters related to transitioning into parenthood may all affect a mother's personality and/or behavior postpartum (Campbell & Cohn, 1991). However, we cannot jump to conclusions and label these mothers as suffering from postpartum depression just because she is in the process of adjusting. Campbell and Cohn (1991) also submit that a woman is better able to adjust when she and her husband are better educated. Better educated spouses in particular were found to be more supportive than their less educated counterparts.
On the note of education, some professionals expect adolescents to be at particular risk for postpartum depression. This group endures even more financial, emotional, and social stress than older women in their 20s and 30s in most cases. However, according to Troutman and Cutrona (1990), postpartum adolescents did not suffer any more from depression than nonchildbearing adolescents. Certainly, 6% met the criteria for major depression at 6 weeks postpartum and 20% met the criteria for minor depression. Regardless, these statistics do not indicate that postpartum adolescents are more susceptible to depression. One possible explanation for this is that about 40% of adolescents terminate their pregnancies through abortion, so those who carry their infants to full term may actually desire a child and would be expected to adjust well (Troutman & Curtona, 1990). Nonetheless, "the lack of difference between childbearing adolescents and other female adolescents in rates of clinical depression should not be construed as indicating that depression need not be a concern for those who work with adolescent mothers" (Troutman & Cutrona, 1990, p. 76). Somatic symptom scores were indeed high for childbearing adolescents as they were for adult mothers, so intervention and assistance is still needed for these girls.
Finally, a study conducted by Field et al. (1985) used interviews of 24 pregnant women in their third trimester to predict postpartum depressive symptoms after their delivery. Interview questions included things like, "Are you single or separated? Do you often feel that your husband (boyfriend) does not love you? Can you honestly say at this time that you really do not desire to have a child?" (Field et al. p. 1152). Participants also completed a Beck Depression Inventory and the Spielberger State/Trait Anxiety Inventory. Ten of the 12 mothers identified by these means were depressed at 4 months postpartum and the remaining two were mildly depressed. Interestingly, these same depressed mothers also expressed more punitive childrearing attitudes and showed less optimal interaction behaviors with their infant upon observation (Field et al.). Fortunately, this study suggests that postpartum depression may be somewhat predictable just by asking simple questions during pregnancy.
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Preventing Postpartum Depression |
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Regrettably, these questions are not usually asked, and postpartum depression is usually dismissed as a normal or natural consequence of childbirth (Nonacs, 2004). Risk factors such as "inadequate social supports, marital dissatisfaction or discord, and recent negative life events such as death in the family, financial difficulties, or loss of employment" (Nonacs, 2004) are often overlooked and not considered severe enough to affect a women after the birth of a baby. It is not surprising then that women commonly report the persistence of depressive symptoms for several months before receiving treatment. As a result, many women are still depressed 1 year after childbirth (Nonacs, 2004).
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Treatment Options |
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For those medical providers who do find some sort of postpartum mood disorders in their patients, there are treatment options available. For postpartum blues, support and reassurance are often enough. Though simple, they can be worth so much to a new mother. Typically, the symptoms of postpartum blues resolve spontaneously and further evaluation is necessary only if symptoms persist for more than 2 weeks (Nonacs, 2004).
The treatment for postpartum depression is a little more detailed. First, medical causes for mood disturbance must be ruled out. A thorough medical history, physical examination, and routine laboratory tests should indicate problems like thyroid dysfunction and anemia, which could potentially explain an individual's depression. For those with mild-to-moderate depressive symptoms, nonpharmacologic options like individual or group psychotherapy are preferable. In particular, time-limited cognitive-behavioral and interpersonal therapy seem to be most effective. Besides these, psychoeducational or support groups are helpful. These treatments may be especially attractive to those mothers who are nursing and who do not wish to take medications (Nonacs, 2004).
For those with moderate-to-severe depression, pharmacologic strategies are preferred. Selective serotonin reuptake inhibitors (SSRIs) are a specific type of medication that is effective in women with postpartum depression. Tricyclic antidepressants have also been found to be useful for women with sleep disturbance, although some studies suggest that women respond better to SSRIs. Of course, there are adverse side effects with both, including insomnia, jitteriness, nausea, weight gain, dry mouth, and sexual dysfunction. Nonetheless, symptoms seem to decrease after 2–4 weeks. If a bout of depression is the mother's first, 6–12 months of treatment is recommended. For those with the most severe postpartum depression, electroconvulsive therapy (ECT) seems to be effective, especially for those with suicidal ideation (Nonacs, 2004).
Finally, those with postpartum psychosis are treated as having a psychiatric emergency and are usually provided with inpatient treatment. Because most patients with postpartum psychosis have bipolar disorder, treatment typically involves a mood stabilizer in combination with antipsychotic medications. ECT may also be effective with this population. As mentioned before, postpartum psychosis must be taken seriously for it is the most dangerous of the postpartum mood disorders and the rates of infanticide associated with it if left untreated are as high as 4% (Nonacs, 2004).
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Effects of Postpartum Depression on the Child |
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Overall, the impact of postpartum mood disorders can be quite significant. Research suggests that a mother's attitude and behavior toward her infant drastically affect mother–infant bonding and development, and depressive symptoms surely interfere with both these processes. In fact:
Children of mothers with postpartum depression are more likely than children of nondepressed mothers to exhibit behavioral problems (e.g. sleep and eating difficulties, temper tantrums, hyperactivity), delays in cognitive development, emotional, and social dysregulation, and early onset of depressive illness. (Nonacs, 2004)
Of course, more severe consequences include infanticide and suicide by the mother's hands in few cases, like that of Mary Ellen Moffitt. Some, like Sr. Carol Juhasz of St. Joan of Arc Catholic Church in St. Clair Shores, wonder, "Why take the baby with her?" (Capeleto, 2004). We may never have an answer to this question, but, according to Capeleto (2004), Mary Ellen struggled with depression and sought treatment for postpartum depression within 2 weeks of Caroline's birth (instead of waiting the recommended 6 weeks). She was reportedly in counseling and took the popular antidepressant Paxil. Recently, Paxil and other antidepressants have been the source of great controversy because such drugs may sometimes increase suicidal thoughts (Capeleto, 2004).
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Conclusion |
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All in all, postpartum mood disorders need to be taken very seriously. Expectant mothers see a caregiver numerous times during and after their pregnancies, so these doctors and nurses have ample opportunities to perform an appropriate screening. Postpartum depression may not look different than depression in other stages of life or seem like a normal consequence of childbirth, but based on the evidence, it indeed exists and deserves proper treatment. As much as mothers often desire to have a baby and be wonderful, they still need social, financial, and emotional support and reassurance that they can perform the job well. Therefore, it makes sense that if the potential losses associated with early motherhood were taken seriously and the women involved were encouraged to grieve, postpartum depression might be seen differently. Ideally, postpartum mood disorders would be seen by the women and their partners, family, and friends as a "potentially healthy process towards psychological reintegration and personal growth rather than as a pathological response to a ‘happy event’." (Nicolson, 1999, p. 162)
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Acknowledgments |
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Conflict of Interest: None declared.
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References |
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