The central distinction is that postpartum depression is a depressive illness in which reality testing is generally preserved. Postpartum psychosis is marked by impaired reality testing—often delusions, hallucinations, paranoia, severe confusion, disorganization, or mania—and requires immediate emergency assessment.
The New York Times story
Shaila Dewan’s New York Times essay, “Justice for Lindsay,” uses the 2026 murder trial of Lindsay Clancy to examine a difficult legal and clinical question: how should criminal responsibility be evaluated when a mother asserts that she was psychotic after childbirth? The story reports that Clancy admitted killing her three children and that her defense contends she was psychotic. Prosecutors dispute that characterization and argue that she acted intentionally. The essay therefore presents competing interpretations; it does not establish a diagnosis or resolve criminal responsibility.
The article’s broader concern is the adequacy of the maternal mental-health system. It recounts Clancy’s repeated efforts to obtain help, including emergency visits, a day program, residential treatment, therapy, a suicide-hotline call, and numerous medication prescriptions. According to the essay, she reported severe insomnia, intrusive thoughts, and worsening distress, yet was not diagnosed with postpartum psychosis before the deaths. Dewan places the case beside the Andrea Yates case and discusses the continuing policy debate over whether postpartum mental illness should affect culpability or sentencing.
The safest conclusion is not that the news account proves either psychosis or medical negligence. Rather, the case illustrates why clinicians must distinguish depressive and anxiety symptoms from a break with reality, investigate rapidly changing symptoms, obtain collateral information, assess safety, and escalate suspected psychosis immediately. A legal insanity determination is also distinct from a clinical diagnosis and depends on the jurisdiction’s legal standard.
One especially important distinction is emphasized throughout: unwanted intrusive thoughts do not, by themselves, establish psychosis. The defining warning signs are impaired reality testing—such as delusions, hallucinations, severe confusion, disorganization, paranoia, or mania. Suspected postpartum psychosis requires immediate emergency evaluation.
Clinical distinctions
| Feature | “Baby blues” | Postpartum depression | Postpartum psychosis |
| Typical pattern | Mild, transient mood lability, tearfulness, worry, and fatigue; usually resolves within about 2 weeks. | Persistent depressive syndrome; commonly begins in the first weeks or months after birth and may arise during the first postpartum year. | Usually abrupt and rapidly changing; commonly begins within days to the first 2 weeks, although later onset can occur. |
| Core symptoms | Mood swings, crying, worry, feeling overwhelmed; functioning is affected only modestly. | Sad or empty mood, loss of interest, guilt or worthlessness, anxiety, fatigue, sleep/appetite change, poor concentration, impaired bonding, and possible suicidal thoughts. | Delusions, hallucinations, paranoia, severe confusion, disorganized thought or behavior, mania or mixed mood state; profound insomnia and agitation may be early warnings. |
| Reality testing | Preserved. | Generally preserved unless the depression has psychotic features. | Impaired or fluctuating; the person may not recognize that beliefs or perceptions are abnormal. |
| Urgency | Support and observation; reassess if severe or longer than 2 weeks. | Prompt clinical evaluation; urgent action for suicidal intent, inability to care for self/infant, or severe deterioration. | Psychiatric emergency: immediate evaluation and usually hospitalization; protect parent and infant and do not leave them alone. |
Sources: NIMH 2023; APA 2025; Toor et al. 2024; Bergink et al. 2025.
The pivotal symptom: loss of contact with reality
Depression and psychosis can overlap in sleep disturbance, agitation, anxiety, depressed mood, impaired concentration, and thoughts of death. The decisive difference is not simply severity or the presence of frightening thoughts. Psychosis involves impaired reality testing: fixed false beliefs, perceptions without an external stimulus, severe disorganization, or confusion. Postpartum psychosis often includes a prominent mood episode—mania, a mixed state, or depression with psychotic features—and symptoms may fluctuate, creating periods that appear deceptively normal.
Intrusive thoughts require careful assessment but should not automatically be labeled psychosis. In postpartum depression, anxiety, or obsessive-compulsive presentations, an individual may experience unwanted, distressing thoughts or images while recognizing that they are inconsistent with her wishes and are not true. By contrast, a delusion is believed to be true, and a hallucination is experienced as a perception. Clinicians should assess insight, intent, plan, command hallucinations, ability to resist, access to means, and the safety of the parent and infant.
Diagnostic and timing cautions
- “Postpartum psychosis” is a clinically recognized emergency, but it is not currently a standalone DSM-5-TR diagnosis. Clinicians diagnose the underlying episode—often bipolar, depressive, or brief psychotic disorder—and may apply a peripartum-onset specifier when criteria are met.
- The DSM peripartum-onset specifier uses onset during pregnancy or within 4 weeks after delivery. Obstetric and public-health practice often monitors perinatal mental health through 12 months postpartum. A 2025 international consensus group proposed specific postpartum-psychosis criteria with onset within 12 weeks; that proposal is influential but is not yet the DSM standard.
- Medical and substance-related causes must be considered, including delirium, thyroid disease, infection, neurologic disease, medication effects, and substance use. A label should follow a full psychiatric and medical evaluation, not a symptom checklist alone.
Risk recognition and response
Risk is elevated with bipolar disorder, a prior postpartum-psychosis episode, a family history of bipolar or psychotic illness, and severe sleep deprivation. However, the absence of a known psychiatric history does not exclude the condition. Rapid onset, near-total inability to sleep, marked activation or agitation, bizarre beliefs about the infant, hallucinations, confusion, or abrupt disorganization should trigger emergency evaluation.
Emergency response: If postpartum psychosis is suspected, keep the parent and infant safe, do not leave them alone together, and arrange immediate emergency psychiatric evaluation—call 911 or go to the nearest emergency department. For suicidal crisis in the United States, call or text 988. The National Maternal Mental Health Hotline is 1-833-TLC-MAMA (1-833-852-6262).
Conclusion
The Clancy case is compelling because it sits at the intersection of medicine, family tragedy, health-system performance, and criminal law. Its educational value lies in recognition and escalation: postpartum depression commonly presents with sustained sadness, anxiety, guilt, fatigue, and impaired functioning, whereas postpartum psychosis includes a loss of contact with reality and may evolve quickly. Neither a news story nor a single symptom can establish a retrospective diagnosis. What the literature does establish is that suspected postpartum psychosis must be treated as an emergency.
For coding, CDI, and HIM professionals, the central principle is to preserve the clinical distinction between postpartum depression, postpartum psychosis, intrusive thoughts, and other psychiatric or medical conditions—without diagnosing from isolated words or symptoms.
Guidance for coding professionals
1. Code the provider’s diagnosis—not the coder’s interpretation
Do not infer postpartum psychosis solely from documentation of:
- Insomnia
- Anxiety or agitation
- Intrusive thoughts
- Suicidal thoughts
- Medication use
- Hallucinations documented without an established diagnosis
- A psychiatric hospitalization
- A later legal allegation that the patient had been psychotic
These findings may support a query, but they do not independently establish the diagnosis.
Conversely, do not reduce documented postpartum psychosis to depression merely because depressive symptoms are also present. Postpartum psychosis frequently includes mania, mixed symptoms, or severe depression with psychotic features.
2. Determine the relationship to the puerperium
When the provider establishes that a mental disorder complicates the puerperium, review assignment of:
- O99.345 — Other mental disorders complicating the puerperium
- An additional code identifying the specific mental disorder
Potential additional codes include:
- F53.0 — Postpartum depression
- F53.1 — Puerperal psychosis
- An applicable F31.- code for bipolar disorder
- An applicable F32.- or F33.- code for major depressive disorder
- F23 — Brief psychotic disorder, when specifically diagnosed
Follow the tabular instructions, Chapter 15 sequencing rules, the complete record, and the code set in effect for the date of service.
3. Do not use O90.6 indiscriminately
O90.6 — Postpartum mood disturbance includes postpartum blues and postpartum sadness. It should not automatically replace a documented postpartum depressive disorder or puerperal psychosis.
“Postpartum mood disturbance,” “postpartum depression,” and “postpartum psychosis” are not interchangeable terms.
4. Use symptom codes cautiously
Possible symptom codes include:
- R45.851 — Suicidal ideations
- R45.850 — Homicidal ideations
- R44.3 — Unspecified hallucinations
- R41.0 — Disorientation, unspecified
- G47.00 — Insomnia, unspecified
Whether a symptom is separately reportable depends on the setting, applicable coding guidelines, and whether it is routinely associated with or integral to the established diagnosis.
A symptom code should not replace a confirmed diagnosis. Likewise, symptoms integral to a diagnosed psychotic disorder ordinarily should not be coded separately unless the circumstances support separate reporting.
Guidance for CDI professionals
1. Clarify the specific psychiatric condition
Vague documentation such as “postpartum mental-health problems,” “postpartum symptoms,” “psychotic behavior,” or “postpartum mood disorder” may not adequately identify the condition.
A compliant query might ask the clinician to clarify whether the documented presentation represents:
- Postpartum depression
- Major depressive disorder with peripartum onset
- Major depressive disorder with psychotic features
- Bipolar disorder, including the current episode and psychotic features
- Brief psychotic disorder
- Puerperal or postpartum psychosis
- Anxiety or obsessive-compulsive disorder
- Delirium
- A substance- or medication-induced disorder
- Another condition
- Clinically undetermined
The query should present relevant clinical indicators without steering the provider toward the highest-weighted or most severe diagnosis.
2. Clarify the relationship to childbirth
Documentation should indicate whether the condition:
- Began during pregnancy
- Began following delivery
- Was preexisting and worsened postpartum
- Is clinically related to or complicating the puerperium
- Is unrelated to the pregnancy or postpartum period
The mere fact that a patient recently delivered does not automatically establish a causal or complicating relationship.
3. Clarify the underlying disorder
“Postpartum psychosis” describes a clinical presentation, but it is not currently a standalone DSM-5-TR disorder. When clinically appropriate, documentation should identify the underlying episode or disorder, such as:
- Bipolar manic episode with psychotic features
- Bipolar mixed episode with psychotic features
- Major depressive episode with psychotic features
- Brief psychotic disorder
- Psychosis caused by a medical condition
- Substance- or medication-induced psychosis
A 2025 international consensus group recommended recognizing postpartum psychosis as a distinct condition within the bipolar-disorders classification, but that proposal has not yet become the operative DSM standard. (Bergink 2025)
4. Distinguish intrusive thoughts from psychosis
This distinction is especially important in provider education and CDI queries.
An intrusive thought may be:
- Unwanted and distressing
- Recognized by the patient as unreasonable or inconsistent with her wishes
- Accompanied by fear that she might lose control
- Present without an intention or plan to act
Psychosis may involve:
- Fixed false beliefs
- Hallucinations experienced as real
- Command hallucinations
- Paranoia
- Severe confusion or disorganization
- Impaired insight
- Belief that harming the infant is necessary, justified, or commanded
Intrusive thoughts still require safety assessment, but they should not automatically be characterized as homicidal intent or psychosis.
5. Seek specificity about safety findings
Documentation should distinguish among:
- Passive thoughts of death
- Suicidal ideation
- Suicidal intent
- A specific plan
- A suicide attempt
- Unwanted thoughts of infant harm
- Intent to harm the infant
- A plan or preparatory behavior
- Command hallucinations
- Ability or inability to resist a command
- Protective actions taken by the patient or family
“Thoughts of harming the baby” is too ambiguous for many clinical, coding, quality, and legal purposes.
Guidance for HIM and record-review professionals
1. Assess the entire clinical trajectory
Postpartum psychosis may fluctuate. A patient may appear organized during one encounter and confused, paranoid, or disorganized during another. A normal-appearing telehealth visit or telephone conversation does not necessarily resolve conflicting observations elsewhere in the record.
Review the chronology of:
- Pregnancy and delivery
- Symptom onset
- Sleep deterioration
- Mood changes
- Emergency visits
- Hotline contacts
- Psychiatric encounters
- Medication starts, stops, and dose changes
- Hospital or residential admissions
- Discharge instructions
- Family reports
- Safety assessments
- Subsequent deterioration or improvement
2. Look for conflicting diagnoses and terminology
Potential discrepancies include:
- Depression in one note and bipolar disorder in another
- “Intrusive thoughts” later described as hallucinations
- Psychosis documented by one clinician but explicitly ruled out by another
- “No suicidal ideation” alongside documentation of a recent attempt
- “Stable for discharge” without reconciliation of recent threats or severe insomnia
- Postpartum depression on the problem list but puerperal psychosis in the discharge summary
Material discrepancies may require clarification, reconciliation, or escalation under the organization’s policies.
3. Examine collateral information
Family members may identify:
- Bizarre beliefs
- Near-total lack of sleep
- Rapid mood changes
- Paranoia
- Uncharacteristic behavior
- Statements about the infant
- Medication nonadherence
- Periods of confusion that were not evident during a brief clinical encounter
The record should identify who supplied the information and distinguish collateral reports from the clinician’s direct observations.
4. Evaluate copy-forward and problem-list integrity
HIM and CDI reviewers should look for:
- Obsolete diagnoses copied into later notes
- A problem list that was never updated after psychiatric evaluation
- Contradictory templated mental-status examinations
- Identical safety statements copied across encounters
- Default “normal” findings inconsistent with the narrative
- Medication lists that omit recent changes
- Discharge documentation that does not reconcile active risks
5. Preserve factual and attribution boundaries
The record should differentiate among:
- What the patient reported
- What a family member reported
- What the clinician personally observed
- What another practitioner previously diagnosed
- What was suspected but not confirmed
- What was concluded retrospectively
For example, “Patient reports hearing a voice” is not identical to “patient has postpartum psychosis.” The latter is a diagnostic conclusion requiring provider evaluation.
6. Avoid retrospective rewriting
Following an adverse event, professionals should not alter prior documentation to make the record appear more complete. Late entries, addenda, and corrections must be:
- Clearly identified
- Dated and authenticated
- Consistent with organizational policy
- Limited to legitimate clarification
- Traceable through the audit trail
The original entry must remain discoverable.
Recommended documentation elements
A strong postpartum psychiatric assessment should address:
- Date of delivery and symptom onset
- Prior psychiatric and postpartum history
- Family history of bipolar or psychotic illness
- Current depressive, manic, psychotic, anxiety, and obsessive-compulsive symptoms
- Sleep quantity and ability to sleep when given the opportunity
- Delusions, hallucinations, paranoia, confusion, and disorganization
- Insight and judgment
- Suicidal and infant-directed thoughts, intent, plan, means, and ability to resist
- Substance, medication, neurologic, endocrine, infectious, and metabolic considerations
- Information supplied by family or other caregivers
- Infant-safety arrangements
- Level-of-care determination
- Rationale for discharge or hospitalization
- Follow-up plan and responsible party
- Instructions describing when and how to obtain emergency assistance
The National Institute of Mental Health identifies delusions, hallucinations, mania, paranoia, and confusion as characteristic postpartum-psychosis symptoms and states that the condition is a psychiatric emergency requiring hospitalization. (NIMH 2024)
Ultimately, coding captures what the clinician established, CDI helps ensure that the diagnosis and its supporting circumstances are clearly documented, and HIM evaluates whether the longitudinal record is complete, internally consistent, properly attributed, and preserved.
References
American College of Obstetricians and Gynecologists (ACOG). 2023. “Clinical Practice Guideline No. 4: Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum.” Obstetrics & Gynecology 141 (6): 1232–1261. https://doi.org/10.1097/AOG.0000000000005200.
American Psychiatric Association. 2025. “What Is Perinatal Depression?” https://www.psychiatry.org/patients-families/peripartum-depression/what-is-peripartum-depression.
Bergink, Veerle, et al. 2025. “Postpartum Psychosis and Bipolar Disorder: Review of Neurobiology and Expert Consensus Statement on Classification.” Biological Psychiatry. https://doi.org/10.1016/j.biopsych.2025.10.016.
Dewan, Shaila. 2026. “Justice for Lindsay?” The New York Times. The Morning. August 23, 2026. https://www.nytimes.com/2026/08/23/briefing/a-murder-trial-in-massachusetts.html?ae=oa&campaign_id=9&context=action_bar_read&emc=edit_nn_20260823&instance_id=180808&nl=the-morning®i_id=127507231&segment_id=225277&user_id=10e745c375590dff74215b724cd7253d.
National Institute of Mental Health. 2023. “Perinatal Depression.” Revised 2023. https://www.nimh.nih.gov/health/publications/perinatal-depression.
Toor, Robina, Ariel Woldesenbet, and Jennifer L. Payne. 2024. “Postpartum Psychosis: A Preventable Psychiatric Emergency.” Focus 22 (1): 64–72. https://doi.org/10.1176/appi.focus.20230025.
CODING RESOURCE
Postpartum Depression and Postpartum Psychosis
Pertinent FY 2026 ICD-10-CM diagnosis codes and documentation considerations
Important: This is an educational reference, not a case-specific code assignment. Code only diagnoses and symptoms documented by the responsible provider, follow the official tabular instructions and payer rules, and apply the code set in effect on the date of service.
Core postpartum codes
| Code | Official descriptor | Use and cautions |
| O99.345 | Other mental disorders complicating the puerperium | Obstetric chapter code for a mental disorder that complicates the puerperium. Use an additional mental-disorder code to identify the condition. When Chapter 15 sequencing rules apply, the obstetric code generally takes precedence. |
| F53.0 | Postpartum depression | Identifies postpartum/postnatal depression, NOS. The tabular list directs the coder to code first O99.345 when applicable. If the provider documents a more specific depressive disorder, review the index and tabular instructions before selecting the final code set. |
| F53.1 | Puerperal psychosis | Identifies puerperal psychosis. The tabular list directs the coder to code first O99.345 when applicable. This code does not replace documentation of the underlying psychiatric presentation when the provider makes a more specific diagnosis. |
| O90.6 | Postpartum mood disturbance | Includes postpartum blues and postpartum sadness. Do not use as a substitute for a documented depressive disorder or psychosis; assign to the provider’s documented condition and applicable tabular guidance. |
Codes that may be pertinent when specifically documented
| Code family/example | Descriptor | Coding point |
| F32.- / F33.- | Major depressive disorder, single episode / recurrent | Severity, remission status, and psychotic features must be supported by provider documentation. Examples include F32.3 or F33.3 for severe depression with psychotic features. |
| F31.- | Bipolar disorder | Postpartum psychosis frequently has manic, mixed, or depressive bipolar features. Select the code for the documented current/most recent episode, severity, and psychotic features; do not infer bipolar disorder from the postpartum setting. |
| F23 | Brief psychotic disorder | May be pertinent when the provider documents brief psychotic disorder. Do not substitute it for an unspecified reference to “postpartum psychosis” without provider clarification. |
| R45.851 | Suicidal ideations | May be separately reported when documented and relevant under applicable rules. Do not use a symptom code to replace a confirmed psychiatric diagnosis. |
| R45.850 | Homicidal ideations | May be separately reported when documented and relevant. Thoughts of harming an infant require precise documentation; do not equate unwanted intrusive thoughts with intent. |
| R44.3 / R41.0 | Unspecified hallucinations / Disorientation, unspecified | Symptom codes may be considered when no definitive diagnosis is established or when separately reportable under setting-specific rules. Hallucinations/confusion integral to a confirmed psychotic disorder are generally not coded separately. |
| G47.00 | Insomnia, unspecified | Use only when separately evaluated/treated and reportable; insomnia may be integral to the psychiatric condition. Prefer a more specific sleep diagnosis when documented. |
Documentation and query checklist
- Relationship to pregnancy/childbirth and whether the disorder is complicating the puerperium.
- Specific diagnosis: postpartum depression, major depressive disorder, bipolar episode, brief psychotic disorder, puerperal psychosis, or another condition.
- For depressive or bipolar disorders: episode type, single versus recurrent, severity, remission, and presence or absence of psychotic features.
- Psychotic findings: delusions, hallucinations (including command content), paranoia, disorganization, confusion, catatonia, and degree of insight.
- Safety findings: suicidal or homicidal ideation, intent, plan, access to means, infant-directed thoughts, ability to resist, and protective actions.
- Possible medical, medication-induced, or substance-induced cause when clinically considered.
- If documentation uses conflicting or nonspecific terms, query the provider rather than inferring a diagnosis from symptoms or the news narrative.
Coding sequence example—not a substitute for record review
If the provider documents “postpartum depression complicating the puerperium” and no more specific depressive diagnosis is established, the tabular directions support O99.345 followed by F53.0. If the provider documents “puerperal psychosis complicating the puerperium,” the corresponding pair is O99.345 followed by F53.1. Final sequencing depends on the encounter, the complete record, official guidelines, and payer requirements.
Official coding sources
CDC/NCHS. 2026. “ICD-10-CM FY26, April 1, 2026 Release.” https://www.cdc.gov/nchs/icd/icd-10-cm/files.html. CMS and NCHS. 2026. ICD-10-CM Official Guidelines for Coding and Reporting, FY 2026.
