52 Lindsay Clancy

[00:00:00] Why does this happen? Gosh, we don't really know. We know there's a historical precedent for it. I can surmise that there's probably a role with estrogen or hormone cycles, but we don't know. We don't know why some people get to this level and others don't. And my mind doesn't appreciate uncertainty.

[00:00:20] That's a big aspect of this case and why it's hard to look at and why we constantly are searching for answers to say, this is what I believe and why I believe. Because that way, instead of it being a fear of something that could happen to me, it's just that thing that happened to her.

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[00:01:17] Disclaimer, this podcast is for informational purposes only. The information provided in this podcast and related materials are meant only to educate. This information is not intended as a substitute for professional medical advice. While I am a medical doctor and some of my guests have extensive medical training and experience, all listeners should consult with a medical professional, licensed mental health provider or other health care provider if seeking medical advice, diagnosis or treatment recommendations.

[00:01:38] Nothing stated in this podcast, nor materials related to this podcast, including recommended websites, texts, graphics, images or anything else should be treated as a substitute for professional medical or psychological advice, diagnosis or treatment. Or put more simply, If you need help like this guy, call your own doctor. Today, I have with me Ellie Jay, former mental health technician at a TMS facility that I worked at.

[00:02:06] Ellie got smart and moved out West and is loving her life out there in Wyoming, but she's been involved with the podcast. She's really helped with social media and promotion because I hate those things and I really appreciate her for it. And she wanted to do a special episode on the Lindsay Clancy case that has captured the hearts and minds of a lot of Americans.

[00:02:34] I just was very caught off guard with this case. It upset me so deeply. I didn't know what to make of it. And I just kind of came to you to talk about it and try and figure out how in the hell did this happen? Is this something that happens a lot? Like as a woman, why is this something that we need to be afraid of or is it not? And just kind of trying to get to the bottom of like, is this a problem with our health care system?

[00:03:02] Is it a problem with this individual? How do we make sure that this never happens again? And kind of looking at this more from the clinical side as opposed to the dramatic social media conspiracy side of it. Yeah. Well, I will say that it will undoubtedly happen again. There are reports of things like this happening going back to 400 BC, I believe.

[00:03:26] So we want to be able to prevent as many of these as possible, even though there will always be folks that slip through the cracks or have such severe and treatment resistant illness that these things will happen. But I 100% agree with you that they're happening too frequently in a disconnected and really kind of captured health care industry in the United States.

[00:03:53] And so when I was kind of trying to figure this case out and understand how could someone be so unbelievably impaired to the point where they could do something this damaging that goes so far against their character that when they wake up out of the psychosis, they're like, oh my God, this is the worst thing in the whole world. Like, I think that what a lot of people are trying to figure out is how impaired can you be under those circumstances?

[00:04:23] People really do struggle to conceptualize, to get over the hump of like, this can actually happen. And it's really scary, especially when you hear about the background for Lindsay Clancy. This is not something that her or her family was aware of. It's not something that she had experienced to this degree at any time in the past.

[00:04:48] She wasn't knowingly diagnosed with bipolar disorder, which is postpartum depression and especially psychosis. I would say most experts would agree that it is in the bipolarity spectrum. I think clearly she was dealing with for months on end before the action.

[00:05:10] And it makes you wonder just how intense some of the auditory commentary internally that was going on for her and how eventually, you know, she probably felt somewhat trapped. That she didn't have a way out that all of these things that she was doing. I mean, you're talking about dozens of different medication changes, a half dozen different providers that saw her and nobody was able to help her.

[00:05:38] So I think over time that probably builds that she really probably was losing her mind. How does somebody get into that state where they can actually carry through the act? It's nearly impossible for me to say. I've never been in that state, but I've seen it in others. And so from my perspective, it's abnormal. Don't get me wrong, but it's not exceedingly rare.

[00:06:04] If I've seen it on inpatient psychiatric units, and I've seen some of the horribly intrusive thoughts and feelings and emotion that goes with those thoughts in women at very critical periods of hormonal fluctuations, postpartum as well as going into menopause.

[00:06:26] When you see a 52-year-old woman who's never been to see a psychiatrist in her life, but does have some family history of bipolar disorder and major depression. And you see this woman, she goes from never seeing a psychiatrist in her life to ending up on an inpatient psychiatric unit, delusional that her whole family has been replaced by imposters.

[00:06:54] Extremely paranoid and psychotic and not responsive to any of the psychiatric medication that we're prescribing to her. It's not as abnormal when you see the Lindsay Clancy case because you have a precedent for it. And what changes? What's the similarity there? Well, the 52-year-old woman was going through perimenopause where you can have dramatic changes in estrogen levels. So, yeah, I'm with you.

[00:07:23] It's hard to imagine carrying out the act. But to say that there's not another condition medically involved, psychiatrically involved, which is what a lot of commentators have stated, I bet you 95% of psychiatrically involved with some elements of postpartum and some elements of really probably mistaken medication management.

[00:07:53] And again, I say mistaken not based on what's in the textbook, what we're told to do, which is first-line SSRI, second-line SSRI, but rather information I've gathered from who I consider to be true experts. And you really got to be cautious when you have any sort of bipolarity and prescribing, in particular, SSRI antidepressants that are known to cause manic or mixed reactions.

[00:08:22] It is difficult for us as humans to conceptualize that somebody could get into a mental state, a mother in particular, where they could end up killing their children. That's really hard for especially lay people that don't work in the field or have not spent a lot of time on inpatient psychiatric units. It's just really hard to understand how something like this could happen.

[00:08:51] So I am by no means an expert on this case. I've just been following peripherally and I'm familiar with other cases historically that follow a similar trajectory.

[00:09:04] Probably most notable is the series that I did on Andrea Yates, who in Houston in the earlier 2000s ended up strangling her five children and drowning them in the bathtub while her husband was away at work. And I think her mother or her mother-in-law was away for like an hour. So a lot of kind of eerie similarities there. But anyway, that's what we're doing here today.

[00:09:31] And just going to try to get a perspective of a psychiatrist who, again, is not an expert on postpartum, but has seen enough cases and is familiar with some of the side effects of medications that may have played a role here. From a bird's eye view, there's some postpartum element to it that is not as obvious as the defense is making it out to be in my eyes because of the time lapse.

[00:09:59] Most postpartum occurs in the first four weeks, though there are secondary hormone shifts that could help to explain it with estrogen that can occur later as the woman is trying to kind of regain her normal menstrual cycle. Periodicity. But she's having command hallucinations. She's having severe persecutory delusions. This is a condition that happens in one in a thousand, maybe two in a thousand.

[00:10:28] But every 25th woman who is postpartum psychosis that's not treated will kill their child. That's a pretty fucking high number when you're talking about the consequences of a really rare condition. But to me, it's just so obvious that there was psychosis involved in this case and all the crap with her husband.

[00:10:53] Maybe there's an outside chance that I'm wrong about it, but he's never been violent with her or the kids. She's never been violent with him or the kids. There's no precedent for these people to just lose their shit, either one of them, and kill their kids without another explanation behind it. So all the stuff with her husband, Patrick, it just drives me crazy because it's clickbait bullshit.

[00:11:21] All the Matt Walsh being just an idiot and not having any idea what it's like to see these things on an inpatient psychiatric unit and have the actual experience to intelligently comment on this. I mean, that guy's he's rage baiting people. He wants views. And the problem is we fall victim to it.

[00:11:46] And we, including myself, click on it to hear what kind of stupid stuff he has to say. It's scary. It's like people want to figure out, is this something that could happen to me? You were talking about how people can't conceptualize what had happened to her, her psychotic state, the fact that she could do that. You're saying that one in 25 women who have postpartum psychosis will kill their child.

[00:12:15] That leads me to believe that these kind of violent, intrusive, scary thought processes could be a little bit natural. And I think that people are so afraid of that being part of human nature, that violent, that terrible, that evil aspect to the point where we're emotionally blanketing this situation.

[00:12:39] We can't even look at it from a clinical standpoint and try and fix it and prevent it because we can't even acknowledge that that could happen to people and that it might be something that does happen to people. You look at places like Skid Row in Los Angeles where there's just huge amounts of people that are psychotic and they've been psychotic. And we're not helping them because they don't want help, but how can they even know if they need it? You know, it's like this is clearly a huge issue.

[00:13:07] And the reason this is getting so much attention is because she's from Duxbury, Massachusetts, a wealthy area, and it's not expected. Can you talk more about that just with psychotic symptoms? And why are we not looking at this and trying to fix it? Our minds, that limbic system, the program, if you will, that runs how we automatically see things, it's very binary. Things are right or they're wrong.

[00:13:36] Somebody is psychotic or they're not psychotic. And this is where things like confirmation bias come in. So when you have a case like this where it's so hard to conceptually say that somebody could do this, it leads to people branching out and saying, well, maybe it's the husband. It must have been the husband. Men are historically violent. They're the ones that commit the mass homicide, mass violence, right? This can't be.

[00:14:05] So we'll take a breadcrumb, a piece of evidence and try to attribute the whole thing to him when there's clearly not the evidence. Her whole freaking defense team is not saying that he did it. So there's obviously no credible evidence. Their job is to defend her. But I think when it comes to Skid Row, you know, it's the same binary thing. It's, well, there's us who aren't susceptible to things like that. And then there's them.

[00:14:34] And we attach all kinds of, well, they must be using drugs. Or if they are using drugs, oh, that's why they're that way. It couldn't possibly be that they were psychotic and they were trying to self-medicate, right? I think there's an underlying fear, whether the person consciously acknowledges or recognizes it, that this could happen to me. Yes.

[00:14:56] And when that fear exists, sometimes it's not the easiest thing to look at in the face. And it's easier to go in your mind to divert, well, it must be some other thing. It must be some obvious explanation. Yes. It's easier when it's an obvious explanation as opposed to she sounds like she was really psychotic, some postpartum elements, maybe some medication side effects. Why does this happen?

[00:15:26] Gosh, we don't really know. We know there's this historical precedent for it. I can surmise that there's probably a role with estrogen or hormone cycles in here, but we don't know. We don't know why some people get to this level and others don't. And my mind doesn't appreciate uncertainty, but sometimes that's where we are in life. Sometimes things are uncertain.

[00:15:51] That's a big aspect of this case and why it's hard to look at and why we constantly are searching for answers to say, this is what I believe and why I believe. This is it. Because that way, instead of it being a fear of something that could happen to me, it's just that thing that happened to her. Yeah. She's other. She's different than me. That's my situation is different. I'm a good person.

[00:16:20] I go to church. I do this. And so that couldn't happen to me. But this person, that's them. They're different. You know, they have psychosis in their family or whatever. Therefore, they're a different type of person than me. I'm not trying to, like, say that anything that happened was okay or that, like, I don't know how much responsibility she has in this because I don't know how with it she was when that all happened.

[00:16:45] But it's just, it's so hard because if you have a heart condition, your symptoms are shown physically. It's like you'll have palpitations or you'll have heart attacks or things like that. But if you're struggling mentally, especially with severe mental illness, such as psychosis, your symptoms are behavioral. And we're so quick to jump at the ethical, like, oh, but their character is bad. They're bad. They did something violent. They smoked a cigarette. They did crack.

[00:17:15] They did this. They did that. They committed a crime. They stole. And it's just so easy to criminalize that or condemn it. Yes. I want to be very explicit here. When somebody is psychotic, and let's use bipolar mania, because that to me is the most obvious and relevant example. Bipolar mania can exist on a spectrum.

[00:17:44] I've seen people who are manic, who are on the less severe end, and they're like, I'm kind of manic right now. I'm not sleeping. There's an awareness. Their frontal lobe, their seat of consciousness is not shut down at that point. But I like to think of it as like a balance or a meter.

[00:18:01] When I have seen and talked to psychiatrists that have done it for more than a decade, and you get the benefit of seeing people who are stable in their outpatient setting, and then they get psychotic and manic. They end up on an inpatient unit if something worse doesn't happen. And they don't remember what happened.

[00:18:23] I have a kid that I've seen for years now that developed mania. Didn't have mania when I started to see him.

[00:18:38] But over time, again, we cannot reliably predict who will be bipolar and who won't, or who has some genetic susceptibility, likely in the case of Donald Schnell, who ended up killing his daughter and granddaughter with no history of that. After no psychiatric history went to his primary care who prescribed him Paxil, paroxetine for sleep. And had a psychotic reaction to it.

[00:19:06] What I'm saying is there's a pendulum of awareness where in a lighter, less intense psychotic episode, maybe they're partially treated with, say, a mood stabilizer and antipsychotic, but their dose isn't high enough. Versus somebody who's in a florid state of mania. This kid, nicest kid, maybe the nicest patient that I have.

[00:19:31] He goes on an inpatient unit, completely manic, doesn't remember 95% of his time there. Doing things that are so out of character for him. Sexist and racist. And again, I'm talking about the nicest kid that maybe I've ever seen. There's a lot of time spent with him outside of that state. People are not aware when they're in the most intense state of mania or psychosis.

[00:20:01] The conscious frontal lobe is shut down. They're jumping around like a mind, like a kid does. You have a kid who's laughing one moment, then they're crying the next. Then they're hitting somebody the next. Their mind is dictating what they do and how they live their life. And that's what happens in florid mania. You've got some objective criteria like their family history and what medications they're on. But it's not always the case where people know what they're doing. And that's hard for people to hear.

[00:20:31] It's hard for me to imagine being in that state. But I've seen it. You see the glazed look. You see that the person is not playing a game. There's not that many good game players or good actors out there to where they can feign this over the course of my short career. And there's psychiatrists with a lot longer careers that see the same thing. You see one version of a person.

[00:20:57] You see the exact same person in a wholly different state of mind at another point in time. You have to have the experience to have that perspective. I feel like we try so hard to get away from the fact that we are mammals. We're animals. Like you see an animal that has rabies, for example. They're acting different. They're rabid. They like they're foaming at the mouth. They have all these symptoms because they're sick. And they might bite you.

[00:21:26] They might act violent because they're sick. It's like how is that any different than somebody who's psychotic? And this illness, psychosis, it's been a thing throughout human history. It's something that has always been there. How are we not able to separate ethics versus illness in this situation?

[00:21:47] How do we move forward and stop emotionally trying to make sense of this rather and just make sure this stops happening? In part because we can't clearly explain it. We can see it. I can tell you that people's what's happening with them internally shifts dramatically with certain illnesses, but we can't explain it.

[00:22:08] Maybe, you know, there's people who get brain infections, either herpes virus infection or other autoimmune conditions that mimic psychiatric symptoms. There's the possibility that all of this, every single person with any form of mental illness, that there's some biological explanation to it or some way that our environment adjusts or changes our biology. And I think if we had a clearer explanation there, it wouldn't be so hard for people to understand.

[00:22:37] But when somebody wants every single answer, I can't provide that. No psychiatrist or psychiatric expert or researcher. Nobody can provide every answer. We can't say why. I mean, you saw the guy for the prosecution that Dr. Mack really got grilled there. And sometimes I kind of felt for him because I don't like that he's testifying for the prosecution. I think he's probably making a pretty penny off of it.

[00:23:04] But some of the questions Reddington's trying to get him to answer yes, no, it's like there's not really a yes, no answer to this. It's a lot more nuanced than that. Maybe one day we'll have more answers and it'll help people to conceptualize it better and accept that. I don't want to say that these people exist because we're talking about the most tragic, worst side of this.

[00:23:28] There's a lot of really, really significant and tremendous benefit to individuals and to society as a whole to have a certain proportion of people with brains like this. We're talking about all the negative stuff, but it's really relevant that I throw that piece in there. People with other conditions in terms of the widespread diversity that a population necessitates in terms of survival and thriving.

[00:23:58] We need diversity and we need some of those brains in there. So Lindsay Clancy has her third child in May or June of 2022 and things look okay. Things are going well for a couple of months. There's a lot of talk in this case about postpartum depression and psychosis. I think it's a little bit more nuanced than that.

[00:24:24] It looked like she was doing okay after the childbirth and maybe there's some hypomania there. As some people have said, running a lot, intense exercising, almost impulsive exercising. But when she was facing the prospect of returning to work, which these situations can be triggered both by life stress and medication.

[00:24:51] So when she's facing the prospect of going back to work and trying to juggle her full-time job along with three children and a marriage and a social life, et cetera, et cetera. It seems like that triggered her to have some pretty intense anxiety and insomnia. And so she goes to Jennifer Tufts. God bless Jennifer Tufts. Brand new out of residency. And one of the first cases that you see who prescribes again by the book. Somebody's anxious.

[00:25:20] They may be having some trouble with sleep. Let's use sertraline, 25 milligrams. Quickly gets increased up to 50 milligrams. And Lindsay Clancy is saying, this doesn't feel right. I don't feel good. But the response is to go up. And again, from a lay person, it's like, why would you do that? If I took something over the counter and it didn't sit well with me, I wouldn't take it anymore. But that's what the textbook says.

[00:25:49] Oh, if they're starting to feel worse, you haven't given them enough time yet. You just need a higher dose. Yes. Yeah. So she isn't responding super well to sertraline. And then she goes back. Yeah, she's not sleeping, which is, again, one of the most objective criteria for bipolar. Not by itself, but somebody who's manic is not sleeping as much. There's mania. There's depression.

[00:26:15] And then there's this state that we call a mixed state where we have elements of both, which is what it looked like she was in. Certainly, as the medication prescribing took off and she ended up having layers added and added and added. But this is somebody who, as of September, starts to try to get in with health care providers, with psychiatric providers.

[00:26:38] At one of the most prestigious psychiatric treatment places really probably in the world. Mass General and McLean Hospital. I mean, you're talking about absolute dinosaurs in the field, in that region. But she starts that in September. By mid-October, she's clearly having a lot of trouble sleeping. She's put on Ativan. She's put on hydroxyzine, probably more so for anxiety.

[00:27:08] The Ativan doses quickly increase. She's put on a really low dose abuse bar, which doesn't really do jack, to be honest with you, in terms of the data. Doesn't really do much for anxiety. Nobody wants to say that, but piss poor medicine. It doesn't have any side effects either. So, but clearly she's having a lot of trouble sleeping. She's starting to have intrusive thoughts. She goes through this rigmarole throughout October, November with a lot of sleep medication, trazodone.

[00:27:38] And then late November, she's switched over to fluoxetine, Prozac. She only takes it for a few days, says again, it makes her feel worse. Classic manic-like reaction for somebody with some bipolar genetics or some bipolar, some predisposition to bipolarity, which we can't reliably predict in our field. We don't just magically know who's bipolar and who's not.

[00:28:04] But these SSRIs can instigate manic-like reactions. Fluoxetine can stay in the system, its metabolites, for four weeks, even six weeks. Late in November, Zolpidem, Ambien, Mirtazapine, Remberon, Clonazepam, Klonopin. Again, obvious problems sleeping. Those are by one of the nurse practitioners, Julie Paul.

[00:28:26] And then she gets put on quetiapine, which is an effective anti-manic agent, not at 25 milligrams at the end of November by Rebecca Gelata, nurse practitioner. And then the next couple of weeks, it is escalation of different benzodiazepines and antipsychotic slash mood stabilizer in quetiapine or Seroquel. She ends up going to the hospital a couple of times because things are getting so bad.

[00:28:53] She's clearly dealing with really intrusive thoughts, really depressed state and a confused state. And towards the end of December, she's finally put on a mood stabilizing dose of quetiapine or Seroquel. But within a couple of days, taken off of it because I didn't like the way that it made her feel. Which to me, I kind of wonder, was there still a remnant of fluoxetine that was contributing to those symptoms?

[00:29:22] Or was it some sort of late onset postpartum? So anyway, through January, it gets worse, it gets worse, it gets worse. She keeps going to see providers and getting prescribed medications. She has a couple of stents or at least one stent, I think, in McLean Hospital end of December to January. And then on, you know, January 24th, I believe she ends up killing her kids and trying to kill herself and jump out the window.

[00:29:50] So you look at this case, it would be a lot different in terms of whether she was psychotic, whether her defense is legitimate. It would be a lot different if she wasn't saying any of this stuff in the four months leading up to the incident. She's like, take a step back from the case and look at it from a bird's eye view. You've got a woman who had some postpartum depression symptoms after the birth of her second child.

[00:30:18] She has her third child. And for a couple of months, she's doing okay. She might be more baseline, just a little hypomanic, feeling good. And as her estrogen system is trying to kind of recalibrate in those first few months after childbirth, she starts to have the onset of more severe symptoms. And she goes repeatedly to try to get care for these symptoms. Intrusive thoughts. Intrusive thoughts.

[00:30:47] And she doesn't get adequate care. And it gets worse and worse and worse. And then she ends up killing her kids. And it's like all of these people out there who are saying, oh, I think her husband did it. That's clickbait bullshit. That is the social media world that we live in. Because, oh, I can't conceptualize a mother taking the lives of her own children. Because I can't conceptualize being psychotic. Because I've never been psychotic.

[00:31:14] I've never been surrounded by people who were psychotic. Like I have on an inpatient psychiatric unit. Not in the presence of drug use. Not in the presence of abnormal medication response even. Just because these things happen. And these things have happened going back to 400 B.C. Hippocrates documents. In 400 B.C.

[00:31:41] A delusional, confused insomniac within a week of giving birth to twins. So there's historical precedence to this. There's a clear story over time that evolves where the person's trying to get help. They're telling everyone that they're really struggling. She probably didn't use the word psychotic. How do you know if you're psychotic, right? You don't.

[00:32:10] You don't think you're psychotic, right? You may know that things are off. But you're not going to use that word. You're just confused. I'm having really intrusive thoughts. You know, I'm having suicidal thoughts. But what happens if you tell a nurse practitioner or an MD that you just met that you're having thoughts about hurting your kids? Like, let's think about that. Would you tell somebody that? What would it take for you to tell somebody that?

[00:32:39] Not being in a telehealth appointment. I'm supposed to evaluate you, get all the information I need, synthesize it, talk to your family members, talk to, you know, other collateral sources of information, review your records, and gain your trust in 15 minutes. And just wipe my hands. Yep, this is what you need. This is the answer. No, that's not how it works.

[00:33:06] I mean, if you're going to really get to the nitty gritty of what's going on in people's heads, you need time. And that's probably one of the biggest travesties about this whole case. Nobody got time. Not enough time with this person to gain their trust, to figure out what exactly is it that's going on with you. I know that you're probably worried about what you tell me and what implications it might have.

[00:33:31] But I want to make sure that you're safe, that your family is safe, that nothing terrible or tragic. Like sometimes other women will have really deep, dark, intrusive thoughts. And there's a normalcy to it. There's an uncontrollable aspect to it in this time frame, whether it's postpartum or whether it is abnormal medication response. You need time to gain the trust of somebody.

[00:33:59] I noticed that in the case that Lindsay Clancy had a MD psychiatrist, but she was also talking to a nurse practitioner that was prescribing her as well. And so then I kind of looked back a little bit further and I realized that I don't always remember in my life that nurse practitioners could also be psychiatrists. And so, I mean, not that they're psychiatrists, but I feel like they have- Psychiatric providers, right? Exactly. Exactly.

[00:34:27] I don't remember that always being something that's been available in my life. And so I look back, I saw that in 2006 was when all nurse practitioners gained that prescriptive power to prescribe, like psychiatric medications and those kinds of things. Do you think that's good or like what you were saying, it's like a nurse practitioner has 25% of the length of training as an MD.

[00:34:55] Do you think that that plays into this case at all? Do you think that is something that affects people's care because a nurse practitioner has more availability or more accessibility to patients rather than an MD? The short answer is there's got to be more balance in training. I don't think that you can come right out of nurse practitioner school and be really good at your job. I think it's hard to come out of medical school and be really good at your job.

[00:35:22] You have got to continue learning under somebody. So I think it makes sense to fill the gaps of healthcare and nurse practitioners certainly play a very important role there. I know a lot of nurse practitioners that are phenomenal at their job, but I also know a lot that are just going to do exactly what the guidelines say. And don't get me wrong, there's psychiatrists that do that too.

[00:35:50] But to me, that's a recipe for disaster because you've got to understand nuance. And to come out and not have anybody overseeing you after the relatively short experience of training, I don't think it's good for patients. They're also being put under the same time constraints that a physician is.

[00:36:15] So you've got less training and you come out and you're expected to figure out what to do with this patient that transferred from an MD who saw him at intake into your care for their second appointment. And you've got 15 minutes to see them. You are blitzing through 15 minute appointments. So as a business owner, that's great. That's wonderful.

[00:36:39] I can hire somebody and pay them significantly less money and continue to pump out patients as many as possible because that's how reimbursement works. Like I wonder if Julie Paul or Rebecca Gelata, the nurse practitioners involved in this case, I'd be curious to see how many patients they were seeing on each of those days. And everybody says, oh, well, we should get more collateral. We should talk to the family. We should win.

[00:37:08] Again, if I'm seeing four patients an hour for eight hours a day and I'm supposed to document around that and I'm supposed to take time to think about the person's case and then I'm supposed to call their family members. It's not realistic. The system is flawed. That's part of it. But it doesn't mean we do away with nurse practitioners. They serve an extremely important role.

[00:37:32] You know, nurse practitioners are also much more under the gun than doctors, I believe. When a nurse practitioner steps outside of the box and does something off label, for example, I've seen so many more nurse practitioners get in trouble for very reasonable decisions. Yes.

[00:37:58] That creates a culture of fear in the nurse practitioner community that you better do what you're told. And again, that works perfectly for the system as a whole from a business, from a money making perspective. But it doesn't work well for the patients. Yeah, absolutely. And it's like, how is it that by following the rules, that risk profile is still involved?

[00:38:25] It's like the least risky thing you can do is like follow the rules. So say you have a patient that's presenting with depression, you prescribe Zoloft, right? And that's supposed to be the safest bet or what you're exactly supposed to do. However, Zoloft for a bipolar patient has a different risk profile. The other day, we talked about how hormones play a role in the psychotic symptoms.

[00:38:54] And I think that's something that's absolutely overlooked because as you're saying, it's something that can occur postpartum. Why would it be occurring postpartum? Probably because of those fluctuations. Just to add to that, Ellie, in a woman's lifetime, the highest levels of estrogen that they're going to have are towards the end of the pregnancy. Literally, throughout pregnancy, estrogen levels rise.

[00:39:20] That rising estrogen throughout pregnancy serves as a natural mood stabilizer. But at the end of pregnancy, estrogen falls off a cliff. It goes from the highest levels to some of the lowest levels that women experience. So it's not just a change in estrogen levels. It's the most dramatic change that many women experience throughout their lifetime.

[00:39:43] If the estrogen can work as a mood stabilizer in the pregnancy, why is that not something that is utilized to balance people's kind of mental state? It's a great question. And I would argue that it's underutilized in this situation.

[00:40:01] Now, there's certainly risks and problematically, there's a lot of risks that a psychiatrist isn't fully aware of and doesn't have all the nuance and the detail to be able to prescribe estrogen and progesterone. It's just not what we do, right? It's a problem within the system. There's also evidence against that being the answer. But there's evidence for it being the answer, too.

[00:40:29] There are case series of women not only being given estrogen who have postpartum psychosis and having significant reduction in their psychotic symptoms. There's also evidence women who are in this psychotic state postpartum have extremely low estrogen levels.

[00:40:50] So is it something that we need to be prescribing to every woman who's got the postpartum blues, which are going to be about half of women, or for every woman that has postpartum depression, about one in 10? The blues probably should not get any estrogen. The folks who are depressed should be on close watch. But the ones who are psychotic, you're talking about a benefit to risk profile.

[00:41:19] The risk of them being psychotic and not being treated are consequences like this, where you have tragedies. You have devastation to an entire family, a community, and in some ways, America as a whole, because people struggle so much to understand this. So I think we should probably be a little bit more aggressive in trying to get more information about what is the role of hormones in this treatment?

[00:41:49] What is the role of estrogen compounds when it becomes psychotic? Because it's just the most common sense looking at it from afar. There's so many pieces of like circumstantial evidence that support this. There is what happens at the end of a woman's childbearing life where they go through menopause. And we see a dramatic increase in psychosis.

[00:42:14] The overall rates are low, but the percentage rates are much higher for a woman who's approaching 50 compared to approaching 40 without any postpartum. You've got postpartum. Obviously, it's what we're here talking about. And most women are aware. And if they've had kids, they've experienced some degree of that.

[00:42:33] The other factor here is in conditions like bipolar disorder and schizophrenia that are associated with psychosis and delusion and auditory hallucinations. You have in women a later onset. One of the theories that I ascribe to for that later onset is the fact that women have a monthly estrogen cycle.

[00:42:58] So not only is that estrogen seemingly protective against the psychotic symptoms, lessening them or preventing them, but they also have these fluctuations month to month where the symptoms may come on less severe, but more predictably each month. So there's precedent. There's a lot of circumstantial evidence that this can be helpful.

[00:43:22] And then there's also a couple of non-really circumstantial evidence. You have a 1999 paper roll of estradiol in purpural psychosis or psychosis around the postpartum period. They looked at a couple of patients that were psychotic who had extremely low serum estradiol.

[00:43:45] They were refractory to neuroleptic or antipsychotic medications, but they responded successfully to estradiol treatment. That's from 1999. There's another 2000 pilot study on estradiol and postpartum psychosis where they took 10 women.

[00:44:03] And they looked at, again, serum estradiol levels at six weeks and found that their baseline serum estrogen levels were lower than the threshold value of menopause or gonadal failure. They scored really high on psychosis symptom scales.

[00:44:24] And within a week to two weeks treatment with estrogen, their estrogen levels rose back to near normal follicular phase levels. And the patients became free of psychiatric symptoms. So, again, there's precedent here.

[00:44:42] Now, if you want the conspiracy theorists to come out, the reason why I think it's not investigated more often, I mean, there's so many huge hormone proponents in the OBGYN world, in the endocrinology world. There are certainly several like me in the psychiatric world. But one of the problems here is the same problem with something like lithium. There's no financial backer for it.

[00:45:07] You cannot conjugate some natural hormone and then turn around and put your stamp on it of your company name and sell it exclusively. In order to get an FDA approval, you've got to spend millions of dollars for that. If you and I both have a hormone company or an estradiol company, well, I'm going to let you spend all the money on the FDA approval trial.

[00:45:34] And then if you get approval, then I'll start marketing my product and I'll sell it and I'll start at zero dollars in the hole. But you'll start at ten million dollars in the hole. So part of this is how the system is set up.

[00:45:49] Prioritize synthetic and unnatural treatments because they cannot patent those natural treatments like lithium, like elements, electrolytes, magnesium, like estrogen, progesterone. And similarly with generics, we find very useful indications for generic drugs.

[00:46:12] But there's not a big backing because when they go generic after 20 or 25 years, that company that originally made, for example, brand name Prozac, now anybody can sell fluoxetine. So they still have the name Prozac, but everybody else can go and make their own fluoxetine. And it's by all intensive purposes, the same drug.

[00:46:37] But yeah, I think it's a it's a certainly in part a system failure. The other factor that you and I talked about yesterday is how disconnected all of these specialties are. Really, what you would need here if we were going to go to more specialization, you'd need somebody that's specialized in OBGYN and psychiatry that can cover that base of where those two intersect or endocrinology and psychiatry.

[00:47:05] Because the psychiatrists see this patient like in this case, they probably never once thought about hormones because it's not in their purview. That's not on their treatment algorithm. It's a separate, you know, we don't do that. They do that. But if you don't talk to them and have a conversation peer to peer clinician to clinician, hey, is this something we could do together?

[00:47:32] Could I recommend hormones and have them come to you and you work with them? But at the same time, OBGYNs aren't exactly chomping at the bit to do things that are out of standard practice because OBGYNs get sued out the ass more than any other specialty.

[00:47:53] So we here in the United States, we've got 12, maybe 15 percent of graduating medical students that go into primary care versus most countries have over 50 percent. And ideally, truly, ideally to me, you'd have a really good family physician who over the course of their career develops a lot of knowledge and skill at managing things like postpartum.

[00:48:21] Otherwise, I just think and kind of part of me thinks it's somewhat intentional that our system is so highly specialized and so disconnected that doctors aren't talking to each other about the patients that they're treating. They may not even be aware that other doctors are involved in the treatment.

[00:48:41] And also kind of isolates people's experiences, because if you're having a particular issue and you want to go to the doctor and they keep referring, referring, referring, and then you can't see the doctor for eight months and you have to go to a specialized ENT surgeon, whatever it is for your issue. And then they have to recommend you somewhere else. It makes you feel like this issue that you're having is unlike other people or that it's not common when a lot of these things aren't common.

[00:49:11] Yeah. And in the wait time, you end up going to see a naturopath and you end up going to see a healer and you get a wellness coach and you you don't. They all call themselves doctor and you don't know what the actual level of expertise is. Right. You're very likely, as Lindsay Clancy was, to see several nurse practitioners as well. There's no knock on a nurse practitioner who's accumulated a lot of experience in an open minded way throughout their career.

[00:49:41] But if they're fresh out, they don't have a whole lot of experience. They have a quarter of the training length and haven't taken nearly as many standardized national exams that they have to pass like you do in medical school and residency to keep moving on to the next level.

[00:50:29] Thanks again for watching and or listening.

[00:51:01] Thanks again for listening.