CHRIS AIKEN: The trial of Lindsay Clancy asked whether she was responsible for her actions. We ask a different question: tracing her treatment and symptoms in the months after childbirth.

KELLIE AIKEN: Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.

CHRIS AIKEN: I’m Chris Aiken, the editor-in-chief of the Carlat Report.

KELLIE AIKEN: And I’m Kellie Aiken, a psychiatric NP and a dedicated reader of every issue.

CHRIS AIKEN: In the 1600’s, citizens of London travelled once a week for a light picnic and live theater. The entertainment was the psychiatric patients of nearby Bedlam hospital. Drawn by charity, curiosity, or the chance to jeer and taunt, visitors lined up on Sundays to peek into the patients’ rooms and gawk at their behavior. The spectacle even inspired a genre of music, the Mad Songs. Among them was Henry Purcell’s Mad Bess of Bedlam:

KELLIE AIKEN: From silent shades, and the Elysian groves,

Where sad departed spirits mourn their loves;

Poor senseless Bess, cloth’d in her rags and folly,

Is come to cure her lovesick melancholy.

CHRIS AIKEN: By the end of the century, things got out of hand. Rowdy visitors provoked the patients. The patients acted out, playing to the crowds. Boorish men pried into the women’s wards. The Governor put up limits, restricting the viewings to three days a year, and by the 1700s the practice had all but ended. This summer, we saw a revival of spectacle. When Judge Sullivan decided to televise the Lindsay Clancy trial, my heart sank. America couldn’t look away, and I couldn’t watch. What happened to Lindsay and her family was a tragedy, and I had the aching thought that it could have been prevented. People pointed out all sorts of criticism – her providers didn’t communicate; she didn’t take her meds; they didn’t check thyroid; and there was that misplaced comma – but I see a different elephant in the room. If Lindsay Clancy had received the right treatment for postpartum psychosis, she would have a 98% chance of recovery. Instead, she got medications that make that disorder worse. But the trial wasn’t about diagnosis and treatment. It was about guilt and innocence: whether Lindsay had enough self-control and moral awareness to resist what she did. For this series, we’ve gathered her medical history from the trial reports and the pending malpractice lawsuit. We’ll walk through her symptoms and treatment, month by month, in the eight months after she gave birth to her son. We’re going to look at why postpartum psychosis gets missed, and it has implications for bipolar mania as well. I know some found the trial – and the way psychiatry looked on the stand – demoralizing. But there’s a lot to inspire here – we can do a better job even with our current tools. Postpartum psychosis is one of the most treatable disorders in the book, when the treatment is right.

KELLIE AIKEN: At the end, we’ll cover a new trial of a nutritional intervention for depression. Here’s a preview in the CME quiz. Earn CME for each episode through the link in the show notes.

1. Which dietary intervention brought about a large effect in depression in a cross-over trial from 2026?

A. Adding a daily serving of fruits and vegetables

B. Reducing ultra-processed foods

C. Restricting calories

D. Eliminating energy drinks

Lindsay Clancy was born in 1990. People who knew her describe a warm, loving, dedicated woman. She excelled in school all the way through her nursing degree at Massachusetts General Hospital, a rigorous program, and then spent nine years working in labor and delivery at that hospital. She married Patrick Clancy at 26, and their first child, a daughter, arrived a year later. After that birth, Lindsay had mild anxiety, but she didn’t need treatment and had no mania and no depression. Two years later, she gave birth to a son, and this time her family noticed a change. She was elated and energized, and felt “amazingly on top of things.” Her thoughts raced. She felt constant pressure to stay active, and she’d spend days at a time decluttering the house in hyperfocused bursts, getting rid of things to simplify her life.

CHRIS AIKEN: Mania has a reputation for drama: trips around the world, fortunes gambled away, random sex parties. But those are rare. The most common behavior in mania is cleaning the house all night like Lindsay did. It can look like OCD, but it isn’t. Manic cleaning is driven and goal-directed. It moves toward something, usually a single-minded focus like aesthetics, feng shui, or, in Lindsay’s case, simplicity. OCD cleaning moves away from something: a fear of germs or disorder, a compulsive need to quiet an irrational anxiety.

KELLIE AIKEN: As often happens, Lindsay’s hypomania turned into anxiety, and that’s when she sought treatment. Her provider offered sertraline. She declined, out of concern about breastfeeding, and her anxiety resolved with meditation, yoga, and a few sessions of therapy.

CHRIS AIKEN: Anxiety is common in hypomania. In one study, people had higher anxiety during mania and mixed states than they did during depression. There are many reasons for this – the lack of sleep, the fear that people are against you, and the frightening feeling that you’re losing control. “Racing thoughts” are one of the ways that people feel that loss of control. On the surface, they sound benign. Who wouldn’t want to think a little faster? But imagine your mind running on its own, with thoughts that jump the rails and veer off in anxious, paranoid, and grandiose directions. You’re speeding down the highway, and the brakes have failed. I’d be alarmed if my arm started to twitch on its own. Losing control of your mind is worse.

KELLIE AIKEN: Here’s how Emil Kraepelin described it in his classic textbook on manic depression, circa 1913: “The thoughts come of themselves, obtrude themselves, impose upon the patients. They complain of too many thoughts: ‘it is stormy in my head... my thoughts are all tattered,’ ‘One thought chases another, and then vanishes just like that.’ ‘I am not master over my own thoughts.’

CHRIS AIKEN: These symptoms are distressing, anxiety-provoking, but we often miss hypomania because the DSM gives the impression it’s not distressing, or that it’s an exalted, desirable state. True, it is the only disorder in the DSM that doesn’t cause significant distress or impairment, but “significant” here means severe enough to require hospitalization or some kind of major intervention. Ask a patient with hypomania whether the symptoms cause any trouble, and you’ll get a different take: Yes. Family conflict, anxiety, sleeplessness, irritability, social embarrassment. If Lindsay had hypomania, it started out euphoric, and then became anxious. DSM paints euphoria as the tell-tale sign of mania, but it’s one of the rarest – only about 1 in 3 hypomanias are this classic, euphoric type. By the time patients come to us, they’re living with the aftermath: depression and anxiety, and they don’t remember the high. At most, the euphoria lasts a few days before impatience, irritability, and an anxious sense of losing control take over. The DSM made progress in 2013 when it dropped the word “pleasurable” from the mania criteria, but it has a long way to go. Its interview manual suggests screening for mania by asking patients if they’ve ever felt unusually happy.

KELLIE AIKEN: Looking for euphoria to find hypomania is like looking for the Statue of Liberty to know if you’re in New York City. That statue may be the most recognizable landmark of the city, but I live there, and you never see her! She’s only visible from the lowest point downtown. It was the same thing in Sydney – you can walk for miles and never see the iconic Opera House. Lindsay’s third pregnancy came three years later, when she was 32. On May 26, 2022, she gave birth to a son. This time the hypomania was stronger. Most women crave sleep after childbirth, but within a week of delivery, Lindsay was getting up before the children at 4 a.m. to start a demanding workout: a three-mile run, thirty minutes on the Peloton, and thirty minutes of aerobics. She filmed her routines, posted them on Facebook, and urged friends to join her. She bought into a multi-level marketing scheme promoting “beach bodies” and spent a lot of money on exercise products she hoped to resell. All of this, her sister said, was not her usual self.

CHRIS AIKEN: When I was a psychiatry resident, an attending at the public hospital took me aside and said, “Chris, here’s how you can tell the manic patients. They keep coming up to the nurses’ station with new questions and demands.” There’s a desire to connect, to engage and interact in mania. They send long texts, call old friends, and upload videos to YouTube. We all want connection, but in mania, the desire is endless and never gets fulfilled. It spirals on, demanding more: more phone calls, more texts, more videos. You think you’ve answered all their questions, and 15 minutes later they knock on your office door with another set. It’s an apt state for the multi-level, or “pyramid,” marketing schemes that Lindsay fell into. I can think of a few manic patients who tried to turn my waiting room into a sales hub for Herbalife and doTERRA.

KELLIE AIKEN: They didn’t have social media or multi-level marketing in Emil Kraepelin’s time, but he got the gist: “Many patients display a veritable passion for writing, and scrawl over sheets and sheets of paper with disorderly effusions… They have a great need of communicating their thoughts, but easily lose the thread”. Three months into this burst of exercise, Lindsay’s mood took an abrupt turn into anxiety and depression. She lost all motivation to exercise. She slept only three hours a night and felt exhausted during the day. Here’s how her husband described it in a 60 Minutes interview:

PATRICK CLANCY CLIP:  “And so yeah, it was, it was October and, um, she went a few nights without sleeping.” “What did she tell you that she was experiencing then?” “She came downstairs one morning, and she said, "I didn't sleep at all last night." And so I said, "That's awful," and, uh, "I'll, I'll take the kids to school. You just focus on, uh, getting caught up on sleep.”" And what happened from there? Like how did it, how did it get worse?” “Well, she went another night without sleeping.”

CHRIS AIKEN: Even if it wasn’t preceded by hypomania, that rapid onset of depression should raise suspicion for bipolar disorder, where rapid on, rapid off depressions – often lasting 1-3 months – are common, particularly early in the course of the illness. We’ll pick up there next week. For now, a research update.

KELLIE AIKEN: Can cutting junk food ease depression? A pilot trial by Dr. Chagwedera and colleagues at UCSF put that idea to the test, published this month in JAMA Psychiatry.

CHRIS AIKEN: The Mediterranean diet treated depression in three earlier trials, but that approach asks patients to do two things at once: eat more healthy food and less junk food. This is the first trial to test the cutting side alone: Asking patients to eat less ultra-processed food.

KELLIE AIKEN: The researchers enrolled 20 adults with depression and at least one metabolic problem, all of whom ate large amounts of ultra-processed food, based on a self-rated dietary scale. In a crossover design, each patient spent four weeks on their usual diet and four weeks without ultra-processed foods, in random order. For the dietary counseling, a physician gave them 45 minutes of education, focusing on the ultra-processed foods in the NOVA classification, and followed up by phone. Medications, therapy, exercise, and sleep stayed the same.

CHRIS AIKEN: When they cut ultra-processed foods, depression fell 11 points on the clinician-rated MADRS, compared with 4 points on their usual diet. Anxiety and depression also fell on the patient-rated scales. Patients found the diet useful, though only moderately easy to follow. Still, they succeeded: cutting their ultra-processed food by 85% on average.

KELLIE AIKEN: Now the caveats. The sample was tiny, the study had no blinding, and patients reported their own diets. The main goal was feasibility, and the mood outcomes were exploratory. The difference here was huge; an 11-point change on the MADRS is about four times what we see with antidepressants. That may be real, and I’ve seen big differences with this strategy in practice, but expectations probably accounted for some of the change.

CHRIS AIKEN: Cutting ultra-processed food is a simple step that helps both mood and physical health. In practice, let patients know that certain foods contribute to depression, and then ask about their intake. In the podcast script on the Carlat website, you’ll find links to the sq-HPF scale they used in the study, and the NOVA classification, which outlines the ultra-processed foods in “Group 4” to reduce. There’s also a free app, Open Food Facts, that scans bar codes to rate foods based on the NOVA system.

KELLIE NEWSOME: We cover the full diet for depression along with 67 other natural therapies in Dr. Aiken's new book: Complementary and Alternative Medicine in Psychiatry: A Carlat Fact Book. Learn what works and what doesn't, with details on drug interactions, dosing, and lab-tested products.