COVID-19 is a new virus and there is a never-ending stream of updates. The uncertainty about the virus and the changes that are rapidly unfolding no doubt make most of us feel on edge. This is normal, and mild anxiety can actually motivate us to take to take action to protect ourselves and others, and to learn more about the pandemic. That being said, we all like stability, routine, and a sense of control over our environments and experience tremendous stress when there are disruptions in our normal lives!
COVID adds a new challenge for pregnant women, women delivering their babies and the postpartum period. All of these can be stressful times and 10-20% of women may develop a perinatal mood or anxiety disorder (PMAD) in the best of times, but COVID adds a very difficult layer. For example, adjusting to parenthood after delivery is challenging under normal circumstances, let alone in the midst of a global pandemic. Concerns about exposure to COVID-19, combined with physical distancing recommendations, can worsen depression and decrease access to the resources, such as health care and social supports, that women typically use to build resilience and promote recovery. Despite these challenges, there are several steps women with a perinatal mood or anxiety disorder can take to optimize their mental health and thrive in the face of COVID-19.
1. Prioritizing Self-Care: Remember the acronym R.E.S.T. (image below) and keep in mind that during these unique times self-care might include limiting/minimizing your media/news consumption and being creative about how you exercise:
2. Access Social Support: Related to Therapy, above, social support can be invaluable at this time - especially for women who have mild (not severe) symptoms of anxiety, depression or stress. However, COVID-19 presents unique barriers to engaging supports, particularly those outside of the home. Partners are a logical first choice, but if one is not present (or able), it may be helpful to seek outside help from family or friends. One silver lining in the COVID-19 cloud is that many restrictions on telehealth – particularly teletherapy and telepsychiatry – have been lifted. Many providers and support groups have quickly pivoted to offer meetings and therapy online. Here are some notable resources for women who are pregnant or new moms struggling with anxiety or depression:
Postpartum Support International offers daily on-line support groups, links to local resources in all 50 states, and an online provider directory.
The Bloom Foundation hosts virtual support groups.
Maternal Mental Health Now has designed a new resource to help you feel prepared to adjust to the emotional demands, joys, and stressors of trying to conceive, pregnancy and parenting. They also partnered with Dignity Health to provide a series of virtual support groups:
3. Experience all of your emotions: Dr. Kessler who is the world’s foremost expert on grief was recently interviewed and suggested that we are currently experiencing several types of griefs (collective, anticipatory). All of the feelings that come along with this COVID-related grief are overwhelming and trying to stop them to avoid feeling sad or angry in our grief will not help.
Kessler says: When you name it, you feel it and it moves through you. Emotions need motion. It’s important we acknowledge what we go through. One unfortunate byproduct of the self-help movement is we’re the first generation to have feelings about our feelings. We tell ourselves things like, I feel sad, but I shouldn’t feel that; other people have it worse. We can — we should — stop at the first feeling. I feel sad. Let me go for five minutes to feel sad."
Give yourself permission to feel. Disappointment around creating a new birth plan? #Anxious about rescheduling your baby shower? Let those feelings move through you and move on. "Let yourself feel the grief and keep moving."
4. Radical Acceptance: Taking the approach of radical acceptance can be important when dealing with an overwhelming situation such as the current one. It is about recognizing and accepting the truth of the situation, even if it is difficult. It is also not burying our heads in the sand. For example, it is not continuing with our daily routine like nothing has changed. Many of our typical routines have changed substantially. It is recognizing what is and where we can act and respond accordingly. It is realizing what is out of our control, but also what is within our control.
Some example of this for pregnant and postpartum women would be:
1. March of Dimes has created a wonderful resource for women to update their birth plan and realizing that what we plan may still not come to happen in COVID times. for this purpose: COVID UPDATED BIRTH PLAN.
2. Evidence Based Birth has high-quality online childbirth education classes.
3. LiveHealthOnline has online lactation and breastfeeding support.
4. National Domestic Violence Hotline helps women create a safety plan HERE.
The Improving Outcomes Program is led by Maternal Mental Health Now and funded by LA Care and Cedars Community Benefit Giving Office. I am proud to serve as the Cedars site PI and our sister medical site is Watts Healthcare. The Improving Outcomes Program was created in response to the gross disparities in adverse birth outcomes, including postpartum depression, experienced by Black women compared to other races. Maternal Mental Health Now is a local non-profit organization dedicated to removing barriers to the prevention, identification and treatment of perinatal mood and anxiety disorders in Los Angeles County. A major goal of the Improving Outcomes Program is to provide training on cultural humility in the medical setting and a partnership with iDREAM for Racial Health Equity was the next logical step.
Another important step is to provide psychoeducation and support for pregnant black women, so they feel comfortable in their medical home before delivery. This 5 session program will be facilitated by Black Women for Wellness, another local organization and will provide communication tips and tools for women to use with their doctors, nurses and hospital staff as they navigate their pregnancy and birth experiences. MMH-NOW will be hosting a series of support circles for pregnant black women at various locations across LA County throughout 2020. The groups will take place at the San Fernando Valley Counseling Center on Sunday afternoons starting February 2nd, at Wellnest on Wednesday evenings starting February 19th, at well Baby Center on Sunday afternoons starting March 8th and Cedars-Sinai Medical Center on Sunday afternoons starting July 12th. Each session is five weeks long and is facilitated by Raena Granberry. Please help us spread the word about these support groups!
Our goal with both arms of this Program is to help change the trajectory of Black women’s maternal and reproductive health. Please check out this special edition of the new Tribune Media syndicated series ALLIES, below! Comedian and “Accidental Activist,” Angelina Spicer, describes her journey from despair to healing and then to advocacy. I am the voice of expertise in the piece, discussing postpartum depression (PPD) and the fact that African American women are 3X more likely to suffer from PPD. I also introduce the Improving Outcomes Program to share we can do in the hospital center setting! Click image below to be directed to KTLA story.
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.
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.
July 2019 UPDATE: The rule became effective on July 1, 2019
What does this bill do?
To learn more, please see Maternal Mental Health Now's Guide to Implementing the 2018 Maternal Mental Health Bills.
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!
Dr. Accortt in the News
May 2020: Hawaii News Now, Sunrise, How to Prevent Anxiety & Depression Before and After Giving Birth
April 2020: The Bump, How to Spot Postpartum Depression in Your Partner or Friend
12/3/19: Quartz, Ten questions about mothers’ mental health could promote resilient pregnancies
5/10/19: CGTN America, US comedian uses her act to turn the spotlight on postpartum depression
5/1/19: KTLA News, How One Comedian’s Battle With Postpartum Depression Turned Laughs Into Legislation
3/20/19: KFI News Radio, FDA Approves First Drug for PPD, Brexanolone (Zulresso) - Correction: Rix states that Dr. Accortt "treats thousands of women at CS" - Thousands of women delivery babies at CS every year. Dr. Accortt does not treat them.
Winter 2019: Cedars-Sinai Discoveries Magazine, Stop The Stigma
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.