When Dr. Suzanne Killinger-Johnson killed herself and her baby by jumping in front of a subway train in August 2000, Heather Raymont envied her. Raymont knew Killinger-Johnson from their days at the University of Western Ontario and, like her friend, was a new mother suffering from a postpartum mood disorder. "I was jealous," says Raymont, "because [in jumping] she'd got rid of this terrible condition."
Within days of the incident, Raymont's PPMD had deteriorated to psychosis. On her way to work, she would see images of the dead doctor clutching a child. Several weeks later she got the unshakable notion that her own baby daughter was in danger and that the only safe place to put her was in the fridge.
Raymont realized she was in trouble and called her father; when he arrived at her west-end home, she opened the front door. "I saw a school of swimming fish where his body should have been," she says. That night she was admitted to Toronto Western Hospital.
Raymont is one of thousands of Ontario women for whom new motherhood is a health risk. Grazyna Mancewicz, a social worker at the maternal support program at St. Joseph's Hospital, believes postpartum distress is "much more prevalent than society is ready to bear."
PPMD can include anxiety, depression, mania, obsessive-compulsive disorder and psychosis -- the latter comprising bizarre ideas and auditory or visual hallucinations. PPMD usually affects a mother hours or days after giving birth, but can also occur months later.
The most common form of PPMD by far is postpartum depression, which ranges from mild "baby blues" to suicidal thoughts.
Statistics about postpartum depression's prevalence are unreliable: older literature puts sufferers at between 10 and 15 per cent of recently delivered mothers, but a newer study suggests the figure is actually 31 per cent. Dr. Donna Stewart, chair of women's health at the University Health Network in Toronto, says around 70 per cent experience mild baby blues.
She says about one in 500 new moms suffer from postpartum psychosis, but some experts believe 80 per cent of recent mothers think about harming their child.
Killinger-Johnson had been taking medication for her condition, but stopped using it because she thought it would harm her breast-feeding baby. She was still awaiting psychiatric care when she was found on a subway platform with six-month-old son Cuyler twice in one night, obviously intending suicide. She was driven home by police, who were satisfied that her family and friends would protect her from making a third attempt. Five hours later, she slipped away from her home and made the jump.
Disturbingly, two years after the extensive coverage given the Killinger-Johnson tragedy, virtually nothing has changed in Toronto with respect to understanding or support for PPMD sufferers.
There are just two PPMD clinics in the city, at St. Joseph's and Toronto East General, and most women won't ever get referred to them because doctors miss their symptoms. Hospital in-patient care isn't much better. Raymont says when she was admitted to Toronto Western, she got a different diagnosis -- and a different medication -- every day for a week.
Experts say general practitioners, who are usually the first to see a sufferer, need more education: early diagnosis and the right medication can save months or years of distress. But Stewart says the main obstacle is cash. Postnatal care has "always been short of resources," she says, "and that hasn't changed since the [Killinger-Johnson case]."
In June, Toronto will host an international conference on PPMD sponsored by Postpartum Adjustment Support Services Canada (PASSCAN). It will focus on developing community supports and will cover spirituality, fathers' roles, intercultural issues, screening for PPMD and effects on the family.
That conference could remind the city that PPMD exists. But why is that reminder only happening now? The troubling fact is that change could have begun only months after the subway incident. There is a well-known method for examining deaths involving a range of sweeping issues -- the provincial inquest system. It's overseen by coroners who find ways to prevent similar deaths through non-binding jury recommendations directed to various groups, individuals and government organizations.
Ontario coroners haven't been shy in calling inquests in other cases where wide-ranging problems need to be addressed, from emergency-room-related deaths and rave fatalities to the death of mentally ill individuals at the hands of police.
So why wasn't an inquest called in the Killinger-Johnson murder-suicide? "With hindsight, maybe we should have done an inquest in this particular case," admits Dr. William Lucas, a regional coroner who was, until recently, supervising coroner for Toronto.
An inquest wasn't held, he says, partly because the additional publicity would likely have spawned copycat subway jumps, and partly because of the extra trauma it would have caused the family. "Sometimes we do feel strongly enough to go through with an inquest anyway," he says, "but we do consider the family, out of respect."
Most surprisingly, Lucas also says the case was deemed atypical: the fact that Killinger-Johnson was a doctor herself "created circumstances which were different from those of other sufferers," he says. "Respect for her professional position interfered with the support systems in place to protect her."
Killinger-Johnson may well have been atypical. She lived in Forest Hill, she was not a single mother, she hailed from a prominent medical family and she was a doctor and psychotherapist who specialized in treating depression. If she couldn't be understood or saved, what hope does any other Toronto mother with PPMD have?
More disturbingly, hindsight also indicates race and class can be a factor in PPMD cases. Mancewicz says she's observed a tendency by support workers to intervene more quickly -- by calling in the Children's Aid Society, for example -- when a black mother confesses to thoughts of harming her child than when a white mother does. "If Suzanne Killinger-Johnson had been black, and on welfare," she says, "the CAS would have been called immediately [following a statement about suicide]."
When it's put to Lucas that coroners may have handled the case differently if an immigrant, non-professional woman had behaved the same way, he says, "I can't challenge that position."
Misunderstandings abound in women's emotional health, and the postpartum experience is particularly complex. "A woman with [PPMD] can have symptoms of anxiety, depression, obsessive-compulsive disorder, psychosis and mania all in one day," says Chris Long of PASSCAN. Long says women are commonly told "it's just new mom stuff" and to wait until their hormones settle down.
Perhaps the easiest disorder to miss in a new mother is mania. "The mom will feel on top of the world -- as though the delivery was perfect and she's ready to do it again tomorrow," says Long. "She's well-groomed and seems orderly and organized, so the nurses let her go home after 24 hours. Then she'll crash."
Long also says postpartum psychosis is easy to miss in some women because symptoms come and go. Minutes after hearing voices or seeing visions, the woman will seemingly be back to normal.
Mancewicz observes that women in North America face special problems that are often overlooked. She cites clients who are educated, have good careers and are unused to asking for help. "This type of sufferer is overwhelmed," she says, "because she thinks she should instinctively know what to do with the baby."
Factors that can predispose a woman to PPMD include an especially traumatic birth; a history of depression, PMS or abuse; and sleep deprivation, a near-guaranteed part of new motherhood. "Sleep is not a cure-all for someone with a postpartum mood disorder," says Long, "although helping a mother get some extra sleep is one of the best supports you can give her."
An Australian study also associated PPMD with Cesarean or forceps delivery, not breast-feeding and single mothers' lack of spousal support. New immigrants are also at risk.
Ontario's cash-strapped hospitals provide little or no home-based follow-up. By contrast, British women receive regular home visits from midwives and health visitors after giving birth. A recent British study shows women who received an extended level of postpartum home care, including screening for depression, were 40 per cent less likely to become depressed.
Soon after the Killinger-Johnson case, Health Canada approached PASSCAN to discuss improved connections between the organization and the federal government.
The result so far is Health Canada has mandated public health units to provide telephone support for PPMD sufferers. Long thinks that's inadequate. In fact, she says, "telephone support is quite dangerous if it's implemented on its own without proper assessment, and without places for the women to be referred to for in-person care."
St. Joseph's maternal support program, tailored to postpartum distress, is run without a physician and uses social workers, nurses and peer counsellors to help women. In one positive offshoot of the Killinger-Johnson case, Mancewicz says her clinic's unusual structure, which it's had to fight for, has received more positive response than before from the medical establishment.
But in the end, Heather Raymont was lucky to have had an excellent family doctor who helped her survive her ordeal. She's still taking antidepressant medication and would like to have another child soon. It's a lifetime away from August 2000, when she compared herself to her old friend Sue. "If somebody so competent could do that," Raymont thought at the time, "then what does that say for me?"