Final Hospitalization and Future Outlook

Hi listeners, exciting news. Crime House Plus and Murder trrue crrime stories are celebrating America's two hundred fiftieth by dropping a four part limited series on the crimes that built America These are the crimes and cases that gave us miranda rights, sparked criminal profiling, and a murder that built America's missing children movement Follow murder trrue crrime stories for a new episode every Monday, leading up to july fourth, or you can listen to all of them right now with Crime House Plus. To join, go to crimehouseplus d. com or if you're listening on Apple podcasts, tap try free at the top of this show's page This is Crime House We've all experienced intrusive thoughts, like waking up in the middle of the night with the sudden fear that something terrible will happen to us or the ones we love or worse that we'll do something terrible to them Usually intrusive thoughts are manageable. We can cope with them through positive self talk or seeking help from a professional. and hopefully we can break out of it. But in some cases, dark thoughts are stronger than any coping mechanism They may even be stronger than medication. and when that happens, nightmares can become reality In the early two thousands, Andrea Yates suffered from thoughts and visions so horrific they left her completely debilitated. until one day, when Andrea decided to do something about it Unfortunately for her family, Andrea's way of addressing her demons was to do their bidding The human mind is powerful. It shapes how we think, feel, love, and hate. But sometimes it drives people to commit the unthinkable. This is sererial killers and Murderous Minds, a crrime House original. I'm Vanessa Richardson And I'm forensic psychologist, Dr. Tran Ingels. Every Monday and Thursday, we uncover the darkest Minds in history, analyzing what makes a killer Crime House exists because of listeners like you. Want even more? Join Crimehouse plus and get both parts of every story dropped on the same Monday, completely ad free. No waiting three days for part two, plus Crime House bonus episodes every month To join go to crrimehouseplus d. com or if you listen on Apple podcasts, tap tryry free at the top of the serial killers and Murderous Minds page Before we get started, be advised. This episode contains descriptions of severe mental health issues and self harm. So please listen with care Today we begin our deep dive on Andrea Yates, a devout Christian and stay at home mother whose one wish was for her family to make it to heaven one day. In Andrea's mind, the only thing holding them back from that dream was the literal demons surrounding them As Andrea's mental health deteriorated over the years, she became convinced there was nowhere safe to run. And in the end, she decided the only way to protect her family was to remove them from this earth herself As Vanessa goes through the story, I'll be talking about things like how extreme religious guilt can feed into delusions, how mounting stress can cause someone to break down, and how all of these issues can culminate into violence And as always, we'll be asking the question, what makes a killer We've all been there. You look up, suddenly life has thrown so much at you that your to do list is completely out of control. For me, it was last month when I moved and I needed to install a cabinet in my bathroom and fix a broken light fixture. I knew just where to turn. Finding a tasker on Task rabbit makes tackling your to do list even easier. And I honestly felt this wave of blissful relief watching a seasoned tasker handle it all in a couple of hours I like to use the same tasker for home repairs, but I know if he's not available, the app is filled with more than qualified taskers. 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From the time she was born, hard work and discipline were in her blood Her father was a soldier who was stationed in Germany after World War two as an Air Force B twenty four navigator At some point, he met Andrea's mother and the two of them moved to Houston, Texas, where Andrea was born in July of nineteen sixty four She was the youngest of five children growing up in a strict Catholic household As a teenager, Andrea had a quiet demeanor, but that didn't mean she didn't push herself. She excelled academically and athletically as a competitive swimmer and she was a valedictorian in high school Then she went to the University of Houston to study nursing. Nursing suited Andrea. It required precision, sticking to the rules, and keeping cool in difficult situations It was right up her alley, and when she graduated, she was ready for the next challenge, working at the University of Texas Cancer Center. Most of her life revolved around her work. Outside of that, she had a small circle of friends. And in nineteen eighty seven, when she was twenty three years old, she had her first serious relationship All this time, Andrea clung to the beliefs she grew up with, including wanting to wait until marriage to have sex And the following year, when it became clear she and her partner weren't aligned with these values, they broke up Afterward, Andrea sank into a deep depression. Not only was she heartbroken, but it was possible she felt conflicted between her religious beliefs and the modern world she lived in If Andrea grew up in a strict Catholic household, it's possible that she may have developed rigid beliefs about purity, marriage, and expectations So when she entered into her first relationship, she likely was very rigid on following this specific moral framework And so she was following the rule and the expectations perfectly, in her opinion, when this relationship ended, she may have viewed it as a spiritual, personal and or moral failure on her part. And that can create feelings of shame, which can be internalized as a belief something is wrong with her or worse, that she failed God in some way which can then turn into catastrophic beliefs about herself That can intensify depression because it adds self blame, isolation and hopelessness on top of grief, and in some cases, religious based fear, especially when you consider that she was conflicted between her religious beliefs and the modern world that she lived in. But it's important to also highlight that religion itself is not the problem For many people, faith is protective. It provides meaning, structure, community, and comfort. But when someone's already vulnerable to depression or rigid thinking or fear based interpretations of religion, then that can sometimes intensify guilt or self blame and hopelessness. Andrea didn't seek formal treatment for what she was going through. She didn't seem to talk to her loved ones about it either Instead, she internalized the pain. But a year later in nineteen eighty nine, Andrea met someone new twenty four year old Russell Yates, who went by Rusty. He was a NASA engineer who lived in the same apartment complex as Andrea in Houston They chatted sometimes, and eventually they realized how much they had in common They were both Christian and shared traditional family values. Rusty hoped to provide for a family of his own one day, and he expected his future wife to stay home to take care of their kids which was exactly what Andrea wanted And as she and Rusty grew closer and he introduced her to a more extreme version of Christianity, she embraced that too Rusty followed the teachings of a traveling preacher named Michael Peter Warnicky, who referred to himself as an ambassador of Christ. and had amassed a small following across the country Michael believed that people could only get into heaven if they followed a strict set of rules on earth. These involved following strict gender rules, having a lot of children, and living as frugally as possible. Michael also opposed institutionalized religion, schools and medicine In other words, he felt that true Christians relied on only themselves to lead virtuous lives. Because in Michael's eyes, demons were always lurking. But by following his doctrine, his followers could avoid their clutches Michael convinced his followers that he preached the Word of God directly from God, so they did what he told them to Rusty had met him when Michael visited his college campus. Now they stayed in touch through letters, as well as Michael's newsletter called The Perilous Times Soon, Andrea formed a close relationship with Michael's wife, Rachel as well, and she and Rusty completely bought into Michael's teachings However, despite how aligned their beliefs were, Rusty also used Michael's teachings to manipulate Andrea Andrea still felt it was wrong to live with a partner before marriage, but Rusty wanted to move in together, and he reminded her of a key aspect of Michael's doctrine, living sparsely. If they lived together, their lives would be less materialistic Andrea was persuaded. In nineteen ninety two, when they were both in their late twenties, they moved in together. And pretty soon Andrea's beliefs were tested again. When Rusty convinced her to have sex with him for the first time Andrea had always planned to wait until she was married to have sex, but Rusty was assertive. And since he didn't feel it was wrong, Andrea didn't challenge him Still, she couldn't help but feel a deep sense of guilt Guilt makes sense when you consider her beliefs around purity, marriage and sex and her concerns about the conflict of her beliefs in the modern world, and the fact that she met someone a year after her first breakup. That may have been something that she was feeling discouraged about But in her previous failed relationship, she held firm to her beliefs. She waited to be intimate until marriage. and when she realized that she and her partner were not aligned on that, the relationship ended. and that resulted in her going into a deep depression. So it's possible that Andrea may have associated her boundaries to rejection, and that can create anxiety And if so, that makes her more vulnerable to Rusty because now there is likely fear of losing this relationship, especially if it's tied to spiritual value or self worth So when he pushes her boundaries Saying no and sticking to her values means risking another rejection or perceived moral failure and possibly falling into another deep depression. But conversely, violating her beliefs means experiencing guilt about that. And because Rusty is confident and convincing and he's using the teachings of Michael, that can cause her to mistrust her own doubt about this too So Andrea may have gone along with something that she did not fully want because she was hopeful it could restore something she felt she needed to preserve. and that is an attachment to Rusty In general, when someone's taught to see things in absolute terms like this, how can that affect the way they handle mistakes or regret? Does that possibly cause someone to internalize that stress? I think it makes it so much harder to process There's less room for nuance or repair, growth, or even context. Things can be seen in very black and white terms are very rigid ways, and subsequently that's how feelings like guilt can be turned into shame. And yes, that can absolutely cause someone to internalize stress because they blame themselves or they'll ruminate, withdraw, or become more rigid to avoid making that same mistake again. But there's also more pressure because they're not really processing the conflict. With absolute thinking, people can start to interpret mistakes as who they are rather than something they did something they can learn from, which I think Andrea is at risk for given just her history here Despite all the mounting shame she was feeling, Andrea never opened up to Rusty about it, so their relationship kept moving forward. and on april seventeenth, nineteen ninety three, they got married Andrea was thrilled. She was already thinking about their future together and told Rusty she wanted to renew their vows on their twentieth wedding anniversary He said they could do it, but only if she could still fit into her wedding dress This didn't seem to bother Andrea, who believed it was her job to look and behave exactly the way her husband expected. And almost immediately after they were wed, Andrea quit her job and they started their family. Between nineteen ninety four and nineteen ninety seven, they had three children, Noah, John, and Paul Andrea's dreams were coming true. came at a cost. She was thrilled to finally become a mother. However, she developed a deep and unshakeable fear that her children may not get into heaven one day. She was willing to do anything to ensure they'd make it past the Parly gates That's where Michael's teachings came in One day before Andrea gave birth to her first child She received one of Michael's newsletters in the mail. She eagerly flipped through the pages and was pleasantly surprised at how relevant it was to what she was going through In his writings, Michael taught that only quote unquote, righteous women could raise righteous children And that in order to gain God's approval, women had to abide by a strict standard of motherhood including giving birth naturally Once Andrea read this, she knew she had to do exactly as Michael said. She gave birth without any medication, which was extremely hard on her, but she committed to it each time And that commitment tells us something important about how Michael's messaging may have landed for Andrea because she seemed to read it as instruction and a standard that she had to meet. That may be because his message spoke directly to fears that she already seemed to have about her worth, value, and spiritual standing. And this comes after a period where Andrea had already compromised on beliefs that were very important to her with Rusty She had wanted to wait until marriage. She had not wanted to live with Rusty before marriage. So if she was already carrying guilt around compromising on those choices and those beliefs, then Michael's message may have felt like a way to repair that guilt somehow. Like if she could become the right kind of wife and mother, then maybe she could make things right overall But at the same time, his message tied her children's spiritual safety to her performance as a mother. And I think the pain medication during childbirth became a test of obedience, faith, and maternal worth His message was giving her an impossible burden It was telling her she needed to have what could arguably be a traumatic birth, but it was also not something that she wasn't already familiar with in her dynamic with Rusty either It sounds like Andrea is experiencing religious OCD. Is that even a thing? And if she is experiencing something like that, how might that relate to the guilt and the symptoms of depression we've seen from her Great question. So religious OCD usually involves intrusive fears about sin, morality or spiritual failure, followed by repeated attempts to neutralize that fear, like excessive praying, for example, or confession, reassurance seeking, or mentally reviewing whether or not you did something wrong. It's very similar to just regular OCD, but it's based around religious themes And I do think there may be elements of intrusive religious fear here, but I do not know that we have enough to call it obsessive compulsive disorder. For that, I would want to see a clear pattern of obsessions followed by compulsions or ritualized behavior. There needs to be that loop for it to qualify. Right now what we see is a fear and her attempt at a solution, even though the solution looks extreme or irrational in hindsight But her guilt does appear to be tied to religious rules and expectations that seem to have started young and then were reinforced by Michael and Rusty and their messages or teachings or beliefs. And remember, Rusty had been using that to his advantage too. So her guilt, fear and her rigid expectations were also being intensified by the people around her It seems like Michael realized just how committed Andrea was to his form of Christianity Because soon, his messages became even more urgent He started sending her tape recordings of himself preaching about how women were inherently unrighteous and that Satan was within her Michael said the only way to banish Satan was to follow his guidance to a T And Andrea believed him T Andrea and Rusty, these ideas seemed reasonable No one knew just how vulnerable she was to Michael's influence and just how dangerous Andrea's beliefs were becoming Media. Hey you What's you doing ing Doom scrolling Looking at other people's vacations, Miami, San Diego, Cancon? Okay, what about you What places will you go Expedia is the one place you go to go places. 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It's called insureanoia And if that sounds like something you're way too familiar with, you should really think about getting NJM insurance They go to great lengths to do what's best for their policyholders likeike providing dedicated reps whose priority is you. And that means you'll find more peace of mind with them Relieve your insuranooyia with NjM insurance by visiting njM. com for a quote today. By nineteen ninety seven, thirty three year old Andrea Yates had three children. Once she finally became a mother, she also became consumed with fear over whether her kids would get into heaven one day. And because of Michael Warnicky's influence over her, Andrea believed that she had to lead a perfectly righteous life in order for her kids to be saved Then in nineteen ninety eight, Andrea and her husband, Rusty made even more sacrifices, inspired by Michael's teachings That year, Rusty purchased a converted greyhound bus from Michael They tossed most of their belongings, sold their house, and started living in the bus In addition to a few personal items, Andrea only kept her sewing machine and cookware However, Rusty rented a storage shed for some of his things, but he left them behind as they embarked on a nomadic lifestyle, traveling to different trailer parks Their life was now the most minimal and isolated it had ever been But even though Andrea believed she was checking all the right boxes to earn her family their spots in heaven The seclusion weighed on her, especially because she stayed home all day, homeschooling the kids The importance of homeschooling was something else Michael preached, and since he and Rusty believed women should be solely responsible for childca Rusty played with the kids, but he never helped feed, bathe or put them to bed The sheer workload was beginning to weigh on Andrea, especially by nineteen ninety nine, when their fourth child, Luke, was born But she kept her head down and did what she believed was her womanly duty. That phrase womanly duty says a lot about Andrea's exhaustion because again, she likely heard that and believed that being tired, overwhelmed, or emotionally deteriorating was something that she was supposed to endure. That is dangerous because if it's true of her that she truly did believe that, she's more likely to ignore any warning signs or signs that she needs a break, signs that she needs help, because she believes that she's not supposed to have help to begin with And it's already weighing on her as it is. She's taking on a lot of the physical and emotional labor after having just given birth no less, and that can be so exhausting in every possible way. And sleep deprivation alone can seriously affect mood, concentration, emotional regulation, and reality testing, especially in the postpartum period On top of that, she's the only parent providing childcare and now is living in isolation. So her mind and body may never have had a real chance to recover from that. And the isolation also reduced the chances that someone could help with childcare, someone in her family, some neighbor, anyone, or someone who could recognize how badly she was deteriorating This is a very risky situation that she is in when you really break it down What are some of the early signs that someone might be suffering mentally? even if on the outside, they're managing their day to day responsibilities Yeah, like you said, it's not a one size fits all all. Some people you can see are visibly struggling, but the reality is a lot of people hide struggle well on the outside, but internally are quietly deteriorating That said, commonly what we often see are changes in sleep appetite, energy, concentration, or emotional regulation, they may seem more irritable, more withdrawn, more tearful, more anxious, or more flat emotionally than usual, like they have a harder time experiencing pleasure or joy Another sign is when everyday tasks start taking much more effort. The person may still be functioning, but everything is more taxing for them. And sometimes the biggest sign is disconnection. They stop reaching out. They stop enjoying things like anedonia laughing or might be physically present but are emotionally somewhere else. These are signs to check in with that person and ask them how they're really doing. Listen more than you talk and offer practical support And if at any point someone indicates that they're in immediate danger, call emergency services. And here in the U.S, we have a crisis line. It's nine hundred eighty eight About halfway through nineteen ninety nine, Andrea reached a breaking point If looking after the children wasn't already challenging enough, Andrea was also caring for her father A few years earlier, he'd been diagnosed with Alzheimer's, and as a former nurse, Andrea helped manage his treatment as his condition worsened There was a lot of pressure mounting on Andrea. It was becoming too much for one person to handle And on june sixteenth, nineteen ninety nine, she felt herself start to break down One day while home with the kids, Andrea suddenly burst into uncontrollable tears Feeling scared and alone, she called Rusty at work He rushed to the bus to check on her, and when Rusty got there, Andrea was sitting in an armchair bent over She was unable to speak and was shaking uncontrollably It can't be overstated how stressful it is to be a caregiver in general. And we're talking, you know a mom or know just a caregiver in general, but let alone a caregiver to someone diagnosed with Alzheimer's disease or any kind of disabling condition That is mentally and physically demanding, but we're adding it on top of our own household demands. So with that, it's likely that Andrea has met her emotional threshold. And when someone's been under sustained stress, exhaustion, and sleep deprivation, the brain can reach a point where it can no longer keep compensating for that anymore. Her body has likely been accumulating stress hormones like cortisol, and now her body needs a release and a reset And sometimes that can look like panic Sometimes it looks like a breakdown. Sometimes it looks like dissociation where the person seems disconnected, shut down, or not fully present. Dissociation can be a way the mind copes with stress that feels like too much to process. So when Andrea is sitting there, shaking, crying, and unable to speak, I would see that as a serious warning sign Her system was overwhelmed. She was no longer just tired or stressed Her mind and body were showing that the demands on her had exceeded her capacity to keep functioning safely at this level. We see what's coming. I mean, this is so much stress. So she doesn't have any freedom and really no ability to self advocate here Would you recommend someone handle the early signs of this level of stress to hopefully avoid reaching this point Yeah, before I get into that for clarity, this is educational information. I'm not acting in place of a therapist or provider for anyone listening. But ideally, you learn to respond before your body forces a shutdown like this. And the first step is understanding your limits and then setting them. Recognize the moments when you're pushing past which you can realistically sustain back or delegate where you can, set boundaries when appropriate, reduce demands when possible, and ask for help before you are completely depleted. And secondly, be honest about how you're really doing, not just with when they check in, but with yourself too, that's so important. But if you're saying, I'm fine, but you're crying more, you're sleeping less, you're feeling numb, you're panicking, you're irritable, hopeless, or you're feeling disconnected, that's information, and that's information you should take seriously And third Learn relaxation, grounding, and stress reduction skills before you desperately need them Use them regularly, like tuns, not just when everything's already unmanageable. And if symptoms are escalating, especially if you are feeling unsafe or detached from reality and you're unable to sleep or you're having thoughts of harming yourself or someone else, that is the point where you need immediate professional support, not later, not after you push through or get your daily workload done or your household chores or whatever the case may be 's now. Your care matters just as much too Unfortunately, Rusty had no idea what to do. He eventually convinced Andrea to go for a walk along the beach with him. It seemed to help at first, but the next day, Andrea's mental state deteriorated even more O day the Aates family visited Andrea's parents at their home. At some point, Rusty went out to run an errand, and when no one else was paying attention to what Andrea was doing, she took a heavy dose of her father's sedative pills Shortly after, her mother found her unresponsive and called an ambulance At the hospital, doctors determined that Andrea could have died, but thankfully, they stabilized her and she was admitted for psychiatric care During that time, doctors documented severe depressive symptoms. Andrea was largely nonverbal, withdrawn, and at times appeared almost catatonic When hospital staff asked her why she'd taken the pills Andrea said she just wanted to stop the intense emotional pain she'd been living with She was officially diagnosed with major depressive disorder and prescribed antidepressant medication, which Andrea wasn't thrilled about. afterfter all, remember her religious beliefs forbade medication Still, it seems like her symptoms improved, because after seven days in the hospital She was discharged and sent home Let's talk about major depressive disorder because it's more than just sadness. It's a mood disorder where a person experiences a sustained period of depressed mood, typically lasting at least two weeks. loss of interest, low energy, changes in sleep or appetite, difficulty concentrating, guilts or worthlessness, and sometimes thoughts of death or suicide It affects how a person thinks, feels, functions, and interprets themselves. And it can range from mild to severe with some individuals experiencing psychotic symptoms. Major depression can show up at many points in life, but it often begins in adolescence or adulthood. And for women, risk can increase during pregnancy and postpartum Perinatal depression includes depression during pregnancy and after childbirth, and symptoms also range from mild to severe. And for Andrea, the timing makes clinical sense. Her most severe symptoms appeared after multiple stressors stacked on top of each other. She had repeated pregnancies, postpartum hormonal shifts derivation four young children, isolation. She was caregiving for her disabled father, and she had intense religious pressure, especially around motherhood And just to clarify, what was commonly known as postpartum depression back then is actually now known as major depressive disorder with peripartum onset After something like this, what are the signs that someone isn't actually out of the danger zone yet, that they're still in it? What does stabilization actually look like Andrea was psychiatrically hospitalized following a suicide attempt. so that's acute imppatient. And in an acute psychiatric setting, treatment typically includes psychiatric medication, psycho education about their diagnostic condition, and individual and group therapy. Providers are also observing the person's behavior, they're monitoring their mental status, and they're documenting whether their symptoms are improving or worsening In that setting, stabilization means is the person sleeping, eating, thinking more clearly and able to participate in basic decision making with the introduction of treatment. And it also means they're not actively suicidal, homicidal, psychotic, or impaired, so much so that they can't care for their basic needs. There's also a realistic safety plan, professional follow up, medication or other treatment if needed, which most of the time there is reduced demands at home is recommended and other adults actively helping. So if someone meets those stabilization requirements, they may be discharged. But being discharged just means that the immediate crisis, what brought them in to that level of care has reduced enough that they no longer require that level of care. They still require ongoing treatment And for Andrea, there are still continued risks here. because first, she was already apprehensive about medication. And given the severity of her deterioration, medication likely played an important role in getting her stabilized If she stopped taking it, the risk of relapse would remain very serious for her. Second, she was likely returning to the same level of stress to her environment that contributed to her acute mental health emergency in the first place. It's unlikely that Michael or Rusty's religious messaging would suddenly change to accommodate Andrea when she returned But more importantly, Andrea seemed to want to believe in their messaging because it offered her hope and structure or a possible solution to her fears. So instead of recognizing the demands as part of the problem, the demands at home, specifically, she might have interpreted again, that her breakdown was proof that she needed to become even more obedient or more righteous, or more self sacrificing when she came home which is clinically concerning to me because if she believes suffering is part of her duty then rest medication, outside help or fewer demands aren't going to feel like appropriate treatments to her, even if they are provider recommended, even if they are medically appropriate So she is likely to be discharged into the same pressure system she was in with the same expectations and that, alongside of medication compliance issues, high risk situation for her So from a clinical standpoint, Andrea had been stabilized That didn't mean her underlying condition had been resolved. It only meant she was no longer in immediate crisis Following her discharge, Andrea's symptoms seemed to improve, but unfortunately, this was short lived Because about a month later, on july twenty first, she attempted to take her own life again this time with a knife Rusty intervened, but Andrea begged him to let her go forward with it Unfortunately, Rusty pulled the knife away and immediately brought Andrea to the emergency room At the hospital it became clear that Andrea hadn't been taking her medication as directed. And on top of that, a nurse discovered several self inflicted wounds, which showed the doctors how much her condition had worsened Even that was just the tip of the iceberg, because Andrea was harboring dark secrets And her demons were becoming impossible to control The Best summer wardrobe consists of pieces you wear on repeat because they're comfortable, versatile, and fit right in anywhere. That's why I love Qints. 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Boss boss, boss boss, boss boss bosses Let's talk business in my office Add new Unstoppables beads to your wash for twenty four hour non stop freshness so you can smell unstoppable In the summer of nineteen ninety nine, thirty five year old Andrea Yates attempted to take her own life twice. She'd been officially diagnosed with major depressive disorder, but refused to take her prescribed medication Anden during her second hospital stay, Andrea described some troubling symptoms she'd never mentioned before. Apparently, she'd been experiencing vivid, intrusive thoughts for some time, including visions of a violent knife attack She told her doctors she didn't know how to stop it, and soon they realized there was another layer to these thoughts Andrea also told them she believed she was evil and had been overtaken by Satan himself She said he was in control of her thoughts and actions The doctors had no way of knowing that Michael Warnicky had planted these ideas in Andrea's mind Regardless, they knew Andrea was experiencing more than depression alone. based on her uncontrollable, distorted thoughts They diagnosed her with postpartum psychosis Postpartum psychosis is a rare but severe psychiatric emergency that can occur after childbirth It involves poor reality testing, delusions, hallucinations, paranoia, confusion, disoriented thinking, severe agitation, insomnia, or rapidly shifting mood. It requires immediate treatment And one important distinction is that intrusive thoughts are not automatically concerned for psychosis. A person can have a terrifying unwanted thought or image, like a violent image flashing into their mind and be horrified by it. That's a common symptom of certain anxiety disorders, for example. But a hallucination is very different. It's a perceptual experience without an external stimulus, like hearing a voice or seeing something others do not. Auditory and visual hallucinations are the ones people tend to think of first But hallucinations can also involve smell, taste, or touch as well because they affect the senses A delusion is also different from an intrusive thought or hallucination. That is a fixed false belief that is not easily changed by the evidence. So when Andrea says she's evil or that Satan's taken her over and that he's controlling her thoughts and actions, that is where the shift from concerns regarding depression turned into psychosis. Now we're talking about a belief that may be detached from reality and organized around religious themes prior mental health history raises her risk as well, which if you recall, did not seem to start with her hospitalization, her first one. Andrea experienced a significant depressive episode after her first serious relationship loss, but she didn't seek treatment at that time. So by the time she was hospitalized the first time, this may not have been a brand new vulnerability for her, at least it doesn't appear to have been. It may have been a longstanding susceptibility to depression that became much more severe under the weight of postpartum changes, sleep deprivation, isolation, caregiving demands, and that religious pressure, which shows you just how important your environment is and other stressors And that is often how severe symptoms develop. It's not one single cause. it's vulnerability plus stressors, which Andrea had multiple of in addition to isolation Through a more modern lens, would you agree with Andrea's diagnosis Yes, I would agree with this. Obviously having not met her, but from what you've shared and what we have here, I would. But one important clarification is that postpartum psychosis is actually not a standalone diagnosis in the diagnostic and statistical manual of mental disorders and never has been. For Andrea, given her history of depression and past psychiatric hospitalization It would likely have actually been diagnosed as major depressive disorder, recurrent, severe with psychotic features, with peripartum onset That's just based on the information we have, again, for educational purposes only. I've never evaluated her, but it could also have been brief psychotic episode, another severe mood disorder, or a different psychotic disorder that's starting to present itself as well. But that's part of the diagnostic process. We start with our first diagnostic impression, and then we update as we get more information, we see them over time. We see how like a brief psychotic episode generally lasts a month Is this lasting longer? We do testing, we get observation and then we make a change Now that doctors felt they had a better understanding of what Andrea was going through, they added a new medication to her treatment regimen. In addition to antidepressants, they introduced an antipsychotic called HalLdL to target her hallucinations and delusions also kept her in the hospital for a while to monitor her progress, and they made sure she got her meds At first, it seemed like they were working. Andrea regained her ability to think clearly and hold conversations She no longer spoke of Satan controlling her Rusty felt relieved, as did Andrea's doctors Andrea wasn't as optimistic though. She didn't want to be on medication. Not only was it against her beliefs, but she was afraid she'd become dependent on it, which scared her It was hard for her doctors to persuade her to take her meds, but eventually they saw enough improvement to transfer her to outpatient care. And eventually, she was released from that program and went back to her normal life By this point, the Yeatateses had moved back into an actual house in Clear Lake, Texas. Rusty thought having some more space could create a more stable environment as Andrea recovered. From the outside, it seemed like everything was back to normal. But at a routine doctor's visit in early two thousand, Andrea admitted to her provider that since returning home, she hadn't been taking her medication a decision Rusty had agreed with We've already seen the risk of Andrea discontinuing medication. When she stopped the first time, she attempted to take her life again and significantly decompensated, which led to a new diagnosis and a new medication. At this point, she is taking medication to treat both depression and psychosis. so stopping them means risking a relapse of both depressive and psychotic symptoms I think we have a good idea why Andrea's hesitant to take her medication. She had already verbalized it, but I think there may have been Possibly a deeper belief underneath that that's worth exploring that's independent of Rusty's reinforcement of her not taking the medication posossible she believed that if she needed medication in order to function as a wife and mother, then that means that she's not righteous enough And if she was not righteous enough, then maybe her children would not be righteous enough either. That would feed directly into her deepest fear that her children might not get to heaven. And imagine what that belief would do to her delusions or hallucinations if those are active So the medication also may have represented failure, weakness or inadequacy And Michael and Rusty's teachings were just reinforcing that rigid thinking It's not clear whether Andrea's medication was tapered off or if she stopped taking it cold turkey Still, at the time Andrea seemed to be functioning well, she cared for her children and did all the housework. To Rusty and Michael, that was all that mattered Unfortunately, even though Andrea seemed okay, she was still battling dark thoughts. She told her friend Debbie that she still believed Satan possessed her Debbie was a Bible teacher, and she read Andrea passages to try and help her overcome her fear of Satan and demons It seemed to work well enough that Andrea soon told Debbie she wanted to get pregnant again However, both Debbie and Andrea's doctors warned her that if she had another child, she'd be at risk of another mental health crisis Andrea was determined. She and Rusty decided the risk was worth it After all, based on their religious beliefs, bringing a lot of children into the world was one of their top priorities And Rusty seemed to think that Andrea's mental health issues had only been temporary So in March of two thousand, Andrea became pregnant again her mental health seems stable throughout her pregnancy And that November, she and Rusty welcomed their fifth child, a little girl named Mary Joy was short lived Because in march two thousand one, tragedy struck when Andrea's father succumbed to his Alzheimer's. The day he died, her mother called her to come help And when Andrea got into their house, she was met with her father's lifeless body This experience seemed to trigger something within Andrea, and it was only a matter of days until her own condition deteriorated rapidly For days, Andrea refused to eat or drink, and she barely uttered a word. She couldn't sleep, staying up all night sitting in an armchair tapping her foot against the floor, or pacing around the house in fixed patterns Not only that, but Andrea refused to let go of her baby, Mary, out of fear that something would happen to her. Andrea's response to her father's death is a good indication that this is not ordinary grief, but rather her system already appeared extremely fragile. and this loss may have overwhelmed whatever stability she had left Grief alone can destabilize someone, but in Andrea's case, this was layered on top of severe depression, prior psychosis that may or may not have returned, sleep disruption, chronic stress, she's still postpartum and healing, and ongoing religious fears. And the circumstances of the death actually matter here too, because she walked into the home and encountered his body herself That can be distressing and traumatic, especially for someone whose mental health is already fragile But her deterioration after suggests another significant psychiatric decompensation, which isn't unusual for someone like Andrea who is not compliant with medication The lack of sleep is especially concerning because sleep deprivation can worsen depression, like we talked about. It can impair reality testing, increase anxiety and intensify psychotic symptoms. So once someone enters that cycle where they're no longer sleeping and their thinking becomes more rigid or fearful, symptoms will escalate very quickly And stress can have a significant impact on your mental health as well. Andrea already has a number of stressors and this experience was a significant stressor for Andrea, whether he was living or after he passed. and it may have been the final stressor to overwhelm her system Do you think Andrea's behavior could be considered normal if those symptoms, those behaviors hadn't persisted for so long Phandria' reactions in isolation could absolutely occur in a normal grief or acute stress experience, but it becomes concerning when the intensity, duration, and level of impairment, when symptoms persist, escalate or interfere with a person's functioning or their ability to care for themselves or safely reality tests, that goes beyond what we would typically consider an expected Grief response After a while, Rusty feared Andrea would harm herself again. so he started searching for an inpatient facility for Andrea By the end of the month, he found a place that was able to treat her. However, Andrea didn't want to go. Rusty and Andrea's brother had to wrestle her into the car Once they arrived, Rusty told the staff that Andrea wouldn't have survived another night at home without professional care Inside, clinicians were met with the same nearly catatonic state Andrea had been exhibiting at home clear signs that she was once again in the middle of a severe mental health crisis This time, Andrea was under the care of a new psychiatrist, Dr. Mohammed Said At this point, Dr. Said hadn't gotten Andrea's records from her previous psychiatrist yet But he arrived at a similar conclusion as Andrea's past doctors that she was clinically depressed, unable to make rational decisions about her own care and posed a danger to herself. However, doror Said and his team didn't provide an evaluation as to whether Andrea posed a threat to others a decision that would later come under significant scrutiny The fact that Rusty believed that she would not survive another night at home tells you just how severe this had become. And that said, there's a lot that stands out about this. Firstly, there's a noticeable pattern that we can see in hindsight, which is Andrea improves in a structured setting, but when she returns home to the same stressors, she stops medication, deteriorates again, and then re enters a crisis That revolving door pattern is very concerning because it suggests the underlying risk factors were never fully stabilized long term, which is exactly what I highlighted as the major risk for her earlier in our discussion. And unfortunately, that's not isolated to Andrea's case. It's something that we frequently see a lot of the time, especially if someone's unhoused and we have to discharge them. Where do they continue their treatment? Where do they continue getting their medication to stay stabilized? It's an ongoing issue Unfortunately, once someone is discharged from acute inpatient care to a lower level of care, we just can't continue monitoring them twenty four hours a day to make sure they're taking their medication or getting their medication. And the medication issue is especially important here because Andrea had already shown significant fear and resistance toward psychiatric medication, and Rusty appeared to support discontinuing it But when someone has severe depression with psychotic features, stopping treatment can dramatically increase the risk of relapse. And once psychosis worsens, insight often worsens too, meaning the person may not recognize they're becoming ill again. And given that this is now her third psychiatric hospitalization in a short period, with two suicide attempts, both with high lethality potential poor medication adherence history. My question is, why wasn't an involuntary medication order considered for her? It's a very high threshold to meet to get one granted. and it requires a judge's order, but in my opinion, it was worth exploring for her. Those orders can begin during an acute hospitalization in some cases continue during outpatient treatment under court oversight. Refusals are documented, and courts may become involved when noncompliance repeatedly results in dangerous decompensation like this. So at least there would be some level of monitoring outside of Rusty