Women with adverse pregnancy outcomes such as hypertension, preeclampsia, diabetes, and preterm delivery are at significantly higher risk than women without these complications of developing early cardiovascular morbidity later in life. Depression is a neglected dimension of maternal morbidity and women with depression are 5 times as likely to progress from maternal morbidity (illness) to mortality (death). Depression is common, 8-13% of pregnant women are diagnosed with depression, and prenatal depression is associated with gestational diabetes, preeclampsia and low birth weight. A growing literature supports links between depression, anxiety and stress and cardiovascular disease (CVD) in older women. As you can see in #6, #10, #13, #15 and #17, all related to CVD below, it is important that women make efforts to reduce stress in their lives as early as possible!
In order to provide clinical cardiovascular screening and preventive care to women who had an adverse pregnancy outcome, we instituted a Postpartum Heart Health Program in January 2015 within the Barbra Streisand Women’s Heart Center (BSWHC). The clinic is tailored to offer a comprehensive cardiovascular risk screening and risk stratification to patients who had an adverse pregnancy outcome. The purpose of the practice is to screen women with adverse pregnancy outcomes for CVD, teach them about cardiovascular health, stress reduction, and offer annual follow-up if desired.
Minissian, M. B., Kilpatrick, S., Eastwood, J. A., Robbins, W. A., Accortt, E. E., Wei, J., & Merz, C. N. B. (2018). Association of spontaneous preterm delivery and future maternal cardiovascular disease. Circulation, 137(8), 865-871.
Fraser, A., Nelson, S. M., Macdonald-Wallis, C., Cherry, L., Butler, E., Sattar, N., & Lawlor, D. A. (2012). Associations of pregnancy complications with calculated CVD risk and cardiovascular risk factors in middle age: the Avon Longitudinal Study of Parents and Children. Circulation, CIRCULATIONAHA-111.
Rich-Edwards, J. W., Fraser, A., Lawlor, D. A., & Catov, J. M. (2014). Pregnancy characteristics and women's future cardiovascular health: an underused opportunity to improve women's health? Epidemiologic reviews,36(1), 57-70.
ACOG Task Force on Hypertension in Pregnancy. Hypertension in Pregnancy. Obstet Gynecol 2013; 122: 1122-31
Burt, V. K., & Stein, K. (2001). Epidemiology of depression throughout the female life cycle. The Journal of clinical psychiatry, 63, 9-15.
Kozhimannil, K. B., Pereira, M. A., & Harlow, B. L. (2009). Association between diabetes and perinatal depression among low-income mothers. Jama,301(8), 842-847.
Furuta, M., Sandall, J., Cooper, D., & Bick, D. (2014). The relationship between severe maternal morbidity and psychological health symptoms at 6–8 weeks postpartum: a prospective cohort study in one English maternity unit. BMC pregnancy and childbirth, 14(1), 133.
Hu, R., Li, Y., Zhang, Z., & Yan, W. (2015). Antenatal Depressive Symptoms and the Risk of Preeclampsia or Operative Deliveries: A Meta-Analysis. PloS one, 10(3).
Grote, NK, Bridge, JA, Gavin, AR, Melville, JL, Iyengar, S, Katon, WJ. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Archives of General Psychiatry. 2010; 67(10), 1012-1024. 23.
Accortt, E.E., Cheadle, A., & Dunkel Schetter, C. (2014). Prenatal depression and adverse birth outcomes; an updated systematic review. Maternal and child health journal, 19(6), 1306-1337
Chapman, D. P., Perry, G. S., & Strine, T. W. (2005). The vital link between chronic disease and depressive disorders. Prev Chronic Dis, 2(1), A14.
Vaccarino, V., Johnson, B. D., Sheps, D. S., Reis, S. E., Kelsey, S. F., Bittner, V., ... & Merz, C. N. B. (2007). Depression, inflammation, and incident cardiovascular disease in women with suspected coronary ischemia: the National Heart, Lung, and Blood Institute–sponsored WISE study. Journal of the American College of Cardiology, 50(21), 2044-2050.
Whang, W., Kubzansky, L. D., Kawachi, I., Rexrode, K. M., Kroenke, C. H., Glynn, R. J., ... & Albert, C. M. (2009). Depression and risk of sudden cardiac death and coronary heart disease in women: results from the Nurses' Health Study. Journal of the American College of Cardiology, 53(11), 950-958.
Jones DJ, Bromberger JT, Sutton-Tyrrell K, Matthews KA. Lifetime history of depression and carotid atherosclerosis in middle-aged women. Arch Gen Psychiatry 2003;60(2):153–60.
Baune, B. T., Stuart, M., Gilmour, A., Wersching, H., Heindel, W., Arolt, V., & Berger, K. (2012). The relationship between subtypes of depression and cardiovascular disease: a systematic review of biological models. Translational psychiatry, 2(3), e92.
I always thought that “wellness” was just another way to say good mental health. Or if I wanted to consider physical health too, that it was the opposite of disease. Wellness is so much more! As you can see in this image, there are actually (at least) six dimensions of wellness, developed by Bill Hettler, MD, in 1976. This interdependent model describes a whole person approach to wellness.
We often focus on the physical and emotional pathways but what encourages me is that we can improve our wellness on the other dimensions and have improvement trickle over! For example, when we take (drag) our kids hiking they eventually get lost in the beauty of our surrounding hills too. We can teach them all about nature while getting physical exercise, spiritually connect with the Earth and God's creatures (if you are religious) and spend quality time with our loved ones, and it all leads to an improvement in our mood and physical health.
I encourage you to give yourself a Wellness Week! Take a few hours and focus on how you can improve your wellness on at least 3 of these dimensions this week. Simple steps like going for a walk with a friend can make significant changes to your health and well-being and improve your wellness on 2 dimensions at a time - physical and social! If you live locally in Los Angeles, please consider stopping by an upcoming Wellness fair (click HERE for link to registration website)! Perinatal Mental Health Care will be participating in this SocalMom Wellness event. Events like these allow me to improve my wellness on at least 4 dimensions at one time - social, intellectual, emotional and occupational! Hope to see you there!
Women are 2-3 times more likely to suffer with depression and anxiety in their lifetime than men. But rates are the SAME before puberty and after menopause! Reproductive mood and anxiety disorders have been my research and clinical interest since my first year in graduate school. I started out by investigating risk for premenstrual dysphoric disorder (PMDD).
PMDD is a chronic condition that significantly affects well-being during the reproductive years. The pattern of symptoms of PMDD is linked to the menstrual cycle, with the onset of symptoms in the late luteal phase (2-3 days before a period begins) and the symptom offset shortly after the beginning of menses. At least five of 11 symptoms are necessary for diagnosis, with at least one of the symptoms being related to mood. Symptoms include depressed mood, anxiety/tension, affective lability (ups and downs), anger/irritability, decreased interest in activities, difficulty concentrating, fatigue, appetite changes, sleep difficulties, feeling out of control and physical symptoms. I found the most common emotional symptom reported was irritability.
PMDD is associated with significant personal and economic costs, increased work absenteeism, reduced work productivity, and reduced quality of life. Sex differences in depression rates suggest that women might be at increased risk for psychiatric illnesses as a result of naturally changing hormonal levels during their reproductive cycle. In addition to high rates of pregnancy, postpartum, and perimenopausal depression, up to 85% of menstruating women exhibit one or more menstrual cycle related symptom, 20–40% report Premenstrual Syndrome (PMS), and 2–9% report PMDD.
My current research focuses on inflammation driving the mood & anxiety symptoms that arise during naturally changing hormonal levels in pregnancy and postpartum. My early research focused on other biological risk factors, for example, I measured the electrical activity in college women's brains. This EEG research has been published and showed that women with PMDD have similar brain frontal brain activity as those with major depression - even if they are in the follicular phase of their cycle (ie. not having mood or anxiety symptoms)! I also published a diagnostic tool for PMDD researchers to use, since none existed in 2002-2005. Links to all of this research can be found in ResearchGate.
If you have trouble accessing any articles, please let me know. I can send you a full PDF (for educational purposes only).
One of the biggest barriers to linking depressed and anxious new moms with the professional help they need is lack of routine screening, education and referral. This is changing in England and Australia where many hospitals already conduct perinatal depression screening programs. At Cedars-Sinai things are also changing. In April 2017 we initiated the new Postpartum Depression (PPD) Screening, Education and Referral Program. This Program received some local media attention last year, see more in my blog post from OCTOBER. With a lot of collaboration and dedication from 4 Departments across Cedars, I am thrilled to report that as of December our screening rate was 99% and remains so!
Screening alone won’t help. And educating alone won’t help. Nurses, social workers & other professionals like OBGYN doctors and pediatricians must be trained to conduct the screening, education AND referral process properly. So we teamed up with Maternal mental health Now and made a PPD Screening Training video!
Some of the tips for screening include:
As we prepared this training video we took into account the initial questions from Cedars nursing staff. One nurse wondered what to do in case a husband, mother-in-law or older child was in the room, “Should I go ahead and ask the questions anyways?” she asked?
No – it is very important to “prepare the room” and allow a new mom to be 100% comfortable to endorse the items.
Another nurse followed up by asking, “How exactly do we politely ask these family members to leave?” and “What do we say if she worries we will call child protective services if she does endorse an item?”
These are all excellent and very important questions. Our training video is finished! It includes the answers to these critical questions (including limits to confidentiality) and several interviews about the protocol, including with an OBGYN doctor, a social worker and a patient representative and will GO LIVE to train the 100’s of Postpartum and Maternal Fetal Care Unit nurses at Cedars next month!
Here is the first minute of the role-model segment of the training video.
For the full 10 minute video please go to Maternal Mental Health NOW's website, and inquire with the Training Director, Gabrielle Kaufman if it has not yet been made available to the public.
Thanks for watching!
I was honored to participate in the California State Senate Health Committee Hearing in Sacramento last week where both AB 2193 (MD screening and insurer case management) and AB 3032 (Hospital Maternal Mental Health) passed and moved on to the Appropriations Committee. Our team, led by 2020 Mom and Maternal Mental Health NOW, included other maternal mental health and health providers as well as survivors (Markeyta Stocker-Sandoval pictured), family members and other advocates.
I testified on behalf of Cedars-Sinai and Perinatal Mental Health Care for a very important bill to provide screening, education, referral and primarily case management for pregnant and postpartum women. This is my testimony.
Human beings are creatures of habit. That can be a very good thing if we have mostly healthy habits! Every one of us, however, has a bad habit like eating too much junk food, not getting enough sleep, smoking, drinking too much or never exercising. If you are thinking of getting pregnant then the time to make a change is now!
I am not suggesting that changing your behaviors is easy. As you can see in the STAGES OF CHANGE image above (Prochaska & DiClemente's Trans-theoretical Model of Change), changing your behavior can take time. Believe me, I have struggled to make behavior changes throughout my life and the process can be long and hard. Lets take my smoking addiction as an example:
STAGE 1: I was a cigarette smoker for 15 years (5 of those years I was a heavy smoker, 1-2 packs a day) and quit exactly 15 years ago! I loved smoking and certainly didn't quit overnight. First, I had to do some deep soul searching to understand WHY I was still smoking after all those years.
STAGE 2: I mistakenly thought that smoking brought stress reduction. I had used smoking as a "break" from studying - in high school, college and grad school. I felt that I worked hard and deserved this one thing to help calm me down. But I also noticed that I felt revved up after smoking too much (which I often did) and that I was smoking at other times too - when I went out with friends, when I had a cup of coffee (major trigger for me), etc. If I didn't smoke (long plane ride) I had a huge headache. I knew it was bad for my lungs, my heart, my skin etc. And once my nephew was born I wanted to be around him without smelling like an ashtray and exposing him to any pollutants. That was the last straw.
STAGE 3: I became determined to cut down. I was in grad school and started reading about how to quit smoking and was being trained in Motivational Interviewing, a highly effective therapy that I currently use with my patients who are motivated to make behavior changes.
STAGE 4: I restricted my smoking to a certain number of cigarettes per day. I went slow, because that worked for me, but for others cold-turkey may be the way to go. After 1 year I had cut down to only 10 cigarettes a day. After 2 years I was down to 5 cigarettes and by the time I met my husband, when I was 27 years old, I was only smoking 1-2 cigarettes a day! So when he encouraged me to quit, I was ready!
STAGE 5: I had to be vigilant at first to maintain this new lifestyle and unfortunately there was collateral damage. I had to stop being friends with an entire group of wonderful people because I knew I couldn't be around them and not smoke. It wasn't their fault, but I had to stay focused and maintain my new healthy habits. I started exercising more and eating right - and that helped me manage stress WAY better than smoking ever did!
Recurrence/Relapse: Don't beat yourself up if you don't stick with your plan 100%. I crave cigarettes often, even 15 years after quitting!
It's never too late to cut down or quit smoking. The benefits kick in immediately and at any age one can extend your life and improve your health! A study in the April 2005 Annals of Epidemiology reported that women who quit before age 30 are no more likely to die from lung cancer than their counterparts who never smoked. Read more HERE.
You may need professional help to achieve your goal (whether its smoking or any other unhealthy behavior), and that is ok. We are here for you!
May is Maternal Mental Health Awareness Month and we are kicking it off today - Its so important that we need an extra day in April to get ready for all of the events, programs and awareness campaigns!
This year Perinatal Mental Health Care has teamed up with the Maternal Mental Health Coalition of Ventura County (MMHCVC) and the Blue Dot Project. The Blue Dot is the national symbol for maternal mental health survivor-ship, support, and solidarity. We will be posting every day this week on Facebook and Instagram about maternal mental health to encourage new moms to speak honestly about motherhood, without shame, and to feel comfortable to reach out for help!
Day 1 - Monday April 30th, 2018 - AWARENESS
If you live in the Los Angeles area, please join the MMHCVC Motherhood Color Walk on Saturday May 19 at 10 am at the Promenade Park in Ventura, CA. The MMHCVC was established in 2017 as a non-profit, volunteer, public and private network dedicated to promoting maternal mental health and wellness through education, advocacy, assessment, treatment and training. Join us as we walk to raise awareness and funds to support moms and families by advocating for Maternal Mental Health!
UPDATE: We raised ALMOST $2500 of our $3000 goal on the 19th. Please click HERE for information about how YOU can still help!!! Even after the event - we hope to reach our goal and serve women all over Ventura County, CA and beyond!
Day 2 - Tuesday May 1st, 2018 - RESEARCH
Perinatal Mood and Anxiety Disorders (PMADs) affect the mother, her fetus/newborn (adverse perinatal outcomes), her partner, older children, extended family and in many cases (e.g. when she cannot return to work because of her symptoms) society as a whole. In addition to treating women with PMADs I am committed to understanding WHY some women develop these problems and also what the consequences are. I was honored to be invited to submit a paper to the Journal of Behavioral Medicine's Special issue on PMADs.
The paper is focused on 2 risk factors for adverse perinatal outcomes (APO; like preeclampsia, preterm birth etc.), prenatal vitamin d deficiency and prenatal depressive symptoms. Having both risk factors placed women at the highest risk for APO!
If you would like to read more click HERE.
DAY 3 - Wednesday May 2nd 2018 - GLOBAL MISSION
Its World Maternal Mental Health Awareness Day! Worldwide, as many as 1 out of 5 women are suffering with perinatal mood and anxiety disorders! The exact statistics vary by country, but its clear that families of all backgrounds are in need.
Read more HERE.
DAY 4 - Thursday May 3rd, 2018 - CLINICAL CHANGE
In April of 2017 I helped initiate a new Postpartum Depression Screening, Education and Referral Program in the Postpartum and Maternal Fetal Care Units as part of my role at Cedars-Sinai. This Program received some local media attention last year, see more in my blog post from OCTOBER. With a lot of collaboration and dedication from 4 Departments across Cedars, I am thrilled to report that as of December our screening rate was 99%! More information will be shared about this Program in the coming months.
More recently, I was honored to be interviewed for Cedars-Sinai's blog post about postpartum mood and anxiety disorders! Please click HERE to learn FIVE things about postpartum depression that you may not know!
DAY 5 - Friday May 4th, 2018 - EDUCATION
One thing I especially love about my career is that I get to educate people about perinatal mood and anxiety disorders (PMADs). In honor of Maternal Mental Health Awareness week, I was invited to 2 different Intensive Care Unit meetings at Cedars-Sinai to educate nurses, doctors and other staff about PMADs.
The Neonatal ICU (NICU) and Maternal-Fetal CU (MFCU) staff understands that women with perinatal complications and those whose babies have medical complications are at even HIGHER risk for PMADs! The rate jumps up to 1 in 3 women! We are working hard to identify women at risk and provide the best holistic care that they need!
Thank you so much for your interest in this work! Again, I want to thank the organizations that we have teamed up with including Maternal Mental Health NOW (who provides our education materials at Cedars-Sinai) the Maternal Mental Health Coalition of Ventura County (MMHCVC) and the Blue Dot Project. The Blue Dot is the national symbol for maternal mental health survivor-ship, support, and solidarity!
We need you! You can easily show your support of this bill and the other 3 in the #4Bills4CAMoms package. Please read more about the bills HERE.
Use 2020 Mom's letter writing web page, which takes less than 2 minutes. Add your address and with a couple of clicks a letter is emailed to your assembly member asking them to co-author all four bills. Do it now, here.
Thank you for caring about the health and well-being of new mothers!
Have you ever wondered what CBT is? It stands for Cognitive Behavioral Therapy, right? Ok, but have you wondered what that actually means?!? Instead of lecturing you about core beliefs, the cognitive triad, automatic thoughts, cognitive distortions and citing hundreds of research articles about how effective this therapy can be, I thought that a few images will help you understand how it works, especially for a new mom.
This first image, thanks to the Parent Connection (UK), shows how our thoughts (also known as cognitions), feelings and behaviors are linked - and these arrows should be bi-directional, because in this example, feeling unsupported or lonely might also cause one to turn away from a partner or a friend.
But thoughts are not facts.
Let that sink in for a minute and then take a look at all of these cognitive distortions we make, many on a daily basis:
So what now?? I have visually shown you how your thoughts influence your feelings and cause you to act in ways that may not help - which is probably not news to you.
The slideshow of images below, thanks to a former patient (all identifying information removed), is a step-by-step example of a thought record that a new mom completed in session to begin to challenge these thoughts and change the resulting feelings and behaviors.
Cognitive behavioral therapy is a process that takes 10-12 fifty minute sessions and thought records are only one piece. I am asked about how this therapy works, on a regular basis (even from the physicians I work with at Cedars), and thought this post might help.
If you have questions, please comment below and/or contact me.
This weekend I went away with girlfriends to celebrate a close friend’s milestone birthday. I am so privileged and grateful to be able to afford to go on a trip like this every few years. We decided to go to Miraval, a beautiful resort outside of Tucson, Arizona. This place is the epitome of self-care and I enjoyed my weekend which included many activities like a rose renewal massage (pictured above), mindfulness meditation, yoga and hiking. This may be what many imagine is self care = too expensive and time-consuming. But that isn’t really an accurate definition.
What is self-care?
Self-care is about identifying your own needs and taking steps to meet them. It is taking the time to do some of the activities that nurture you as a living breathing human being who cannot (and should not) always be on autopilot. And it is particularly important for new and expecting moms. Why?
The only way I can answer that question is to tell a story. I used to fly a lot during my college and grad school years. The flight attendants always described the safety features of the plane and I got very used to ignoring this spiel. Then I had a baby. This time when the flight attendant said, “in case of a change in cabin pressure an oxygen mask will drop in front of you and you should put on your own oxygen mask before you assist anyone else,” I thought - Wait, what? I take care of myself first?!?! I decided on that very flight that I was learning something very important: Only when we first help ourselves can we effectively help others. Caring for yourself is one of the most important things you can do for yourself. It is also one of the easiest things to forget. But you benefit greatly from self care and so do others in your life.
Why is Self Care Important specifically for Women?
Women spend most of their lives nurturing others. This can be fulfilling and still have significant ramifications:
"When we find ourselves focusing more on others than ourselves, we become worn out, stressed out and run down. For those of us who spend time helping and caring for others, it is too easy to neglect our own needs. It’s like “running on empty” when we don’t take the time to re-fuel. We spend so much time and effort caring for our partners, children, pets, friends, family members, employers and employees. Add to that the numerous volunteer activities, errands, housework, family functions, meetings, etc.—and there isn’t much time left for caring for ourselves. Women need to balance the stress and activity of daily life with activities that bring a sense of peace and well being to their minds and bodies. Women who neglect their own needs and forget to nurture themselves often become unhappy, have low self-esteem and feel resentment. Self care can help you avoid this outcome by treating yourself as a worthwhile person who is valuable, competent and deserving."
*Fort Garry Women's Resource Centre
What are Some Examples of Self Care Activities?
Practicing self care does not have to cost a lot of money. In fact there are many things that you can do that are free or inexpensive:
My personal goal is to do one of these things for myself every single day. Sometimes I only get 10 minutes for myself. Other times I can spend an hour. But I make the time, because I am worth it and because it allows me to be the best mother, wife, psychologist, scientist, daughter, sister, friend etc. that I can be.
Dr. Accortt in the News
9/11/18: USC Center for Health Journalism, Cedars-Sinai PPD Screening Program May be Model for State
Summer 2018: Cedars-Sinai Catalyst Magazine, The Helping Hand of Los Angeles Funds Postpartum Depression Screening Program, scroll down to page 40 of magazine
5/18/18: TODAY.com, Alyssa Milano on Postpartum Anxiety
5/3/18: Cedars-Sinai Maternal Mental Health Research
10/19/17: Cedars-Sinai Postpartum Depression Screening Program
3/24/17: MomCo. App for Social Support
Dr. Accortt is a California licensed clinical psychologist. When she isn't seeing patients in private practice she conducts research in the OBGYN department at Cedars-Sinai. She will update this page with important maternal mental health news and research.