Caucasian sad woman sitting at the sofa with depression


Disclaimer: This case study deliberately examines an unusual situation to increase the interdisciplinary need for further critical management. Although hypothetical, this scenario as well as the characters are fictitional  and as such do not violate anyone’s privacy, security, or breach of information according to HIPPA guidelines.  G. Davidson. RN.

Case: On March 23, 2023, 26-year-old Queen Esther (G3P3) gave birth to her third child, a bouncing baby boy. She was sending her baby back to the nursery to be fed and held but shrugged it off because she was tired all the time. Her husband, Jobahan, is a CPA who can support a large family. He comes from a family of fifteen and wants to have more children.

Queen Esther is an only child and is happy with her three boys. She wants to have her tubes, but she is afraid to tell Jobahan because she wants to please her husband. Queen Esther has been worried sick about future pregnancies; her youngest just had his first birthday. Queen Esther  noticed she was having trouble sleeping and having thoughts of self-harm. She went to the hospital, with the hope of getting help. However, Queen Esther was seen and released after her lab work and urine results revealed she was six weeks pregnant. Queen Esther would often feel for the loaded gun she had been carrying around. That night, Queen Esther shot and killed herself while her family slept in silence.

What could be identified as contributing factors to Marianna’s death?

  1. Different values about family and family size than her spouse.
  2. Subclinical depression and unknown history of postpartum depression.
  3. Unplanned pregnancy
  4. She obviously had a plan. Possibly hoping someone would ask her the right questions.

What are some open-ended questions to ask during the assessment process?

  1. History of mental health?
  2. History of mental health in the family?
  3. History of previous suicide attempts or self-harming behaviors? Look for signs of cutting on the arms and hands.
  4. History of eating disorders such as anorexia or bulimia?
  5. Are there any underline identity and body dysmorphic issues?
  6. Subclinical (short-lived and low-level) depression?
  7. Clinical- persistent, pessimistic, worthless, hopeless, helpless, feelings of guilt.
  8. Seasonal depression?
  9. Functional Impairment?

History of complications during pregnancy such as PIH/MDM/Hyperlipidemia/Stroke/Sickle Cell or other blood disorders?

  1. Drugs and alcohol use during pregnancy?
  2. Financial or other worries?
  3. Hormonal imbalance- Progesterone (Lower progesterone levels were noted in women with high intentionality).


Studies show that “Up to 20% of postpartum deaths were due to suicide.”  And “suicide during pregnancy and the postpartum period is often attempted through more lethal methods than suicide in the general female population.”  Most suicide cases related to severe maternal depression occur around 12 months after delivery. Therefore, early detection and treatment intervention is critical for all clinicians. Especially those at the entry of access to health care.


Postpartum depression contributed to a significantly higher rate of suicide and a shorter time to suicide after childbirth. Younger age, the winter season, subclinical depression, and anxiety were negative predictive factors associated with suicide in individuals with postpartum depression.  Women with comorbidities such as diabetes, hypertension, hyperlipidemia, and stroke, were associated with a greater risk of suicidality.

To prevent suicide among the postpartum depression population, clinicians should be observant of symptoms of subclinical depression and anxiety among their patients. The routine screening of postpartum depression and the close monitoring of patients with this condition might be required for the detection of suicidality and for early coordination with mental health services.

Reference: Lindahl, V.; Pearson, J.L.; Colpe, L. Prevalence of suicidality during pregnancy and the postpartum. Arch. Women’s Mental Health 20058, 77–87.