Susan Hatters Friedman

Neonaticide: Phenomenology and considerations for prevention

This article explores the phenomenon of neonaticide, the murder of an infant during the first day of life. Characteristics of maternal neonaticide offenders in industrialized countries were identified based on a systematic literature review. Neonaticides were most often committed by poor, relatively young, single women who lacked prenatal care. Efforts to better prevent these tragedies should include improved sex education and contraceptive access. Two legal responses to the problem of neonaticide, Safe Haven laws utilized in the United States, and anonymous birth options in Europe are discussed.

Characteristics of Women Who Do Not Seek Prenatal Care and Implications for Prevention

OBJECTIVES To describe characteristics of women without prenatal care and their reasons for not seeking prenatal care. DESIGN Retrospective record review. SETTING Urban, academic medical center. PARTICIPANTS Women without prenatal care whose pregnancies reached the third trimester, who presented to the hospital for delivery or immediately postpartum for a 7 year period. METHODS Records were reviewed for factors including socio-demographic factors, history of pregnancy/miscarriage/abortion, social supports, abuse history, history of substance use, toxicology results, history of mental illness or mental retardation, and the reason for lack of prenatal care. RESULTS Among 211 women with no prenatal care, the primary reasons were noted: 30% had problems with substance use; 29% experienced denial of pregnancy; 18% had financial reasons; 9% concealed pregnancy; and 6% believed they did not need prenatal care due to multiparity. Women with substance use disorders were significantly more likely to be older, unemployed multigravidas. CONCLUSIONS Nurses should target specific groups of women for education and intervention based on their rationale for not seeking prenatal care.

Disposition and health outcomes among infants born to mothers with no prenatal care

OBJECTIVE This study assessed infant disposition and health outcomes among offspring born to mothers without prenatal care, based on maternal characteristics and the reason for lack of prenatal care (i.e., denial of pregnancy, concealment of pregnancy, primary substance use, financial barriers and multiparity). METHODS A retrospective record review was completed at an urban academic medical center. Subjects were women who presented at delivery or immediately postpartum with no history of prenatal care (N=211), and their infants. RESULTS Infants of mothers with substance use problems had the highest rates of referral to child protective services and out-of-home placement at discharge, though mothers with other reasons for no prenatal care also experienced both referral and placement. Infants born to mothers using substances experienced the highest rates of neonatal intensive care unit admission, and the lowest mean birth weight. CONCLUSIONS Though those without prenatal care experienced a variety of adverse outcomes, substance use problems were most frequently correlated with adverse infant outcomes. Mothers who either had lost custody of other children or with substance use problems were at highest risk of losing custody of their infants. Those who denied or concealed their pregnancy still frequently retained custody. PRACTICE IMPLICATIONS Among mothers without prenatal care, those with substance use problems were least likely to retain custody of their infant at hospital discharge. Custody status of the mothers other children was also independently associated with infant custody. Mothers who denied or concealed their pregnancy still often retained custody. Referrals of mothers with no prenatal care for psychiatric evaluation were rare, though referrals to social work were frequent. Child protective services occasionally did not investigate referrals in the denial and concealment groups. Healthcare providers should be aware of the medical and psychological needs of this vulnerable population of infants and mothers.

Menopause knowledge and subjective experience among peri- and postmenopausal women with bipolar disorder, schizophrenia and major depression.

This study examined concerns regarding menopause among women with schizophrenia/schizoaffective disorder (N = 30), women with bipolar disorder (N = 25), and women with major depression (N = 36). The three groups were compared regarding knowledge of menopause, expectations of effect of menopause, and menopause-related quality of life. All women had deficits in fund of knowledge regarding menopause. More than half (53.8%) agreed that they felt more stressed due to menopause or approaching menopause, and 51.6% felt that menopause has had a negative effect on their emotional state. Perceptions of menopause effect on emotional states between the three groups were similar. The top five symptoms experienced by women with serious mental illness were all problems related to psychological issues: feeling depressed (88%, N = 80), feeling anxious (88%, N = 80), feeling tired or worn out (87%, N = 79), feeling a lack of energy (86%, N = 78), and experiencing poor memory (84%, N = 76). Larger-scale studies evaluating the effects of menopause on serious mental illness are needed to clarify how menopause affects illness outcomes in women with serious mental illness.

Mothers who kill: evolutionary underpinnings and infanticide law

Women who kill their children present a profound challenge to accepted notions of motherhood and the protection offered by mothers to their children. Historically, societies have varied in the sanctions applied to perpetrators of such acts, across both time and place. Where penalties were once severe and punitive for mothers, in modern times some two dozen nations now have infanticide acts that reduce the penalties for mothers who kill their infants. Embedded within these acts are key criteria that relate (a) only to women who are (b) suffering the hormonal or mood effects of pregnancy/lactation at the time of the offence which is (c) usually restricted to within the first year after delivery. Criticisms of infanticide legislation have largely centered on inherent gender bias, misconceptions about the hormonal basis of postpartum psychiatric disorders, and the nexus and contribution of these disorders to the offending in relation to issues of culpability and sentencing. Important differences between female perpetrators relative to the age of the child victim have also highlighted problems in the implementation of infanticide legislation. For example, women who commit neonaticide (murder during the first day of life) differ substantially from mentally ill mothers who kill older children. However, despite these shortcomings, many nations have in recent years chosen to retain their infanticide acts. This article reviews the central controversies of infanticide legislation in relation to current research and fundamental fairness. Using evolutionary psychology as a theoretical framework to organize this discussion, it is argued that infanticide legislation is at best unnecessary and at worst misapplied, in that it exculpates criminal intent and fails to serve those for whom an infanticide defense might otherwise have been intended.

Parents Who Kill Their Children

1. Susan Hatters Friedman, MD* 2. Joshua B. Friedman, MD, PhD† 1. *Senior Instructor in Psychiatry and Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio; Consultant Forensic Psychiatrist, Mason Clinic, Waitemata District Health Board, Auckland, New Zealand. 2. †Fellow in Child Protection Paediatrics; Te Puaruruhau Child Protection Unit, Auckland District Health Board, Auckland, New Zealand. After completing this article, readers should be able to: 1. Identify commonalities among women who commit neonaticide (killing the infant in the first day after birth). 2. Describe commonalities among parents who kill their children for reasons related to parental mental illness. 3. Delineate the role of the pediatrician in the detection of both denial of pregnancy in teenagers and of parental depression and psychosis. 4. Discuss potential strategies for preventing parents from killing their children. Child homicide is a significant public health problem in America. In 2005, homicide was the fourth leading cause of death in both the 1- to 4-year-old and 5- to 14-year-old age groups. (1) Most young children who are homicide victims are killed by a parent. Of American children younger than 5 years of age who were murdered over the 30-year period from 1976 to 2005, 31% were killed by their fathers or stepfathers, and 29% were killed by their mothers or stepmothers. (2) Of the 40% not killed by a parent, most were killed by male acquaintances. The average number of children up to 5 years of age known to be murdered by their parents in the United States was 344 per year (range, 246 to 426). (2) Underestimations of death rates, however, pervade the literature. There are hidden pregnancies and hidden corpses, medical examiner misjudgments of homicide as being accidental or natural (eg, sudden infant death syndrome) or undetermined, and unwillingness to place responsibility on a grieving parent. (3) In addition, estimates of the frequency of maltreatment and death vary, depending on the data source. Filicide is defined as the homicide of a child by …

Menopause-related quality of life in chronically mentally ill women

Objective: Menopause is an important life event that has not yet been well characterized among women with severe mental illness. Our goal was to evaluate menopause-related quality of life among severely mentally ill women. Method: We conducted a cross-sectional assessment of perimenopausal and postmenopausal women, ages 45–55, diagnosed with schizophrenia/schizoaffective disorder, bipolar disorder, or major depression, who were receiving inpatient or outpatient psychiatric care. Women were compared regarding menopausal symptoms and quality of life using the Menopause Specific Quality of Life Scale (MENQOL). Results: Women with severe mental illnesses who were peri- and post-menopausal experienced considerable vasomotor, physical, sexual, and psychosocial symptoms related to menopause. On seven of 29 MENQOL items, women with major depression reported problems significantly more often than women with other serious mental illnesses. Conclusions: This preliminary study indicates that psychiatrists and other physicians should consider the frequency and overlap of menopausal and psychiatric symptoms among women with serious mental illness in this age group.

Clinical Characteristics and Length of Hospital Stay among Older Adults with Bipolar Disorder, Schizophrenia or Schizoaffective Disorder, Depression, and Dementia

Although many older adults with serious psychiatric illnesses share common concerns, such as medical comorbidity, personal loss, greater propensity for adverse medication effects, and greater dependence on others for basic needs such as transportation, individualized treatment needs must be differentiated by underlying psychiatric disorders. This retrospective study evaluated clinical characteristics and resource use among 137 older adults with bipolar disorder, schizophrenia or schizoaffective disorder, depression, and dementia who were discharged from an urban, academic medical center’s inpatient geropsychiatric unit. The authors found women to be significantly overrepresented among individuals with schizophrenia or schizoaffective disorder compared to those with bipolar disorder, depression, and dementia (P= .034). Among those with bipolar disorder, anticonvulsant medications were predominantly used as mood stabilizers, with only the rare use of lithium. Individuals with schizophrenia or schizoaffective disorder were the youngest group of patients; individuals with dementia were the oldest group (P< .001). This shows significant differences in clinical characteristics among hospitalized older adults with serious mental illnesses. Additional studies are needed on outcomes of serious chronic psychiatric illnesses in later life to optimize care environments for older adult psychiatric patients.

Psychopathology in a galaxy far, far away: the use of Star Wars' Dark Side in teaching

Star Wars is well known, timeless, universal, and incorporated into shared culture. Trainees have grown up with the movies, and based on their enduring popularity, attending psychiatrists are likely to have seen them too. This article highlights psychopathology from the Dark Side of Star Wars films which can be used in teaching. These include as follows: borderline and narcissistic personality traits, psychopathy, PTSD, partner violence risk, developmental stages, and of course Oedipal conflicts.

Suicide and murder-suicide involving aircraft

BACKGROUND This is a systematic review of suicide and homicide-suicide events involving aircraft. In aeromedical literature and in the media, these very different events are both described as pilot suicide, but in psychiatry they are considered separate events with distinct risk factors. METHODS Medical databases, internet search engines, and aviation safety databases were searched in a systematic way to obtain relevant cases. Relevant articles were searched for additional references. RESULTS There were 65 cases of pilot suicide and 6 cases of passengers who jumped from aircraft found. There were also 18 cases of homicide-suicide found involving 732 deaths. Pilots perpetrated 13 homicide-suicide events. Compared to non-aviation samples, a large percentage of pilot suicides in this study were homicide-suicides (17%). DISCUSSION Homicide-suicide events occur extremely rarely. However, their impact in terms of the proportion of deaths is significant when compared to deaths from accidents. There is evidence of clustering where pilot suicides occur after by media reports of suicide or homicide-suicide. Five of six homicide-suicide events by pilots of commercial airliners occurred after they were left alone in the cockpit. This, along with a sixth incident in which active intervention by a Japan Air crew saved 147 lives, suggests that having two flight members in the cockpit is potentially protective. No single factor was associated with the risk for suicide or homicide-suicide. Factors associated with both events included legal and financial crises, occupational conflict, mental illness, and relationship stressors. Drugs and/or alcohol played a role in almost half of suicides, but not in homicide-suicides.