Investigating and Treating Maternal Mental Health as a Key to Improving Cardiovascular Health

The integration of routine mental health screening and care during and after pregnancy can reduce the risk of adverse pregnancy outcomes and improve maternal cardiovascular health. This is according to a new scientific statement published today in a Go Red for Women® special issue of the Journal of the American Heart Association, a peer-reviewed, open-access journal of the American Heart Association. This special issue focuses on research addressing gender differences in cardiovascular disease and their implications for care.

The new scientific statement, Optimizing Mental Health During the Perinatal Period: An Update on Maternal Cardiovascular Health, highlights the need to support maternal cardiovascular health through comprehensive mental health screening during the perinatal period (pregnancy through one year postpartum). Cardiovascular problems are the leading cause of maternal death. The new statement summarizes the evidence on the link between mental health issues and adverse cardiovascular outcomes, highlights effective management strategies and integrated care models, and identifies current challenges and future directions for improving maternal health outcomes.

Mental and Cardiovascular Health in Mothers

“It is critically important that we redefine maternal cardiovascular health to include mental health, as there is solid evidence linking mental health to cardiovascular outcomes,” said Garima Sharma, M.D., FAHA, writing group chair and director of preventive cardiology and women’s cardiovascular health at Inova Schar Heart and Vascular in Fairfax, Virginia. “We also recognize the importance of providing clinicians with guidance on how to incorporate psychological health testing into the perinatal period and focus on a holistic approach that emphasizes the connection between the mind and heart.”

The maternal mortality rate in the United States is two to three times higher than estimates from other high-income countries and has worsened since the COVID-19 pandemic, with significant disparities among people of underrepresented races and ethnicities. The mortality rate for non-Hispanic black women giving birth is 2.6 times higher than for non-Hispanic white women. Perinatal mental illnesses, such as depression and anxiety, are among the leading causes of maternal mortality in the United States and are associated with adverse pregnancy outcomes and long-term cardiovascular sequelae. Mental health, often used interchangeably with mental health, encompasses emotional, social, and functional well-being and is influenced by factors such as living conditions, traumatic events, and daily stressors.

An estimated 52% of women of childbearing age report a history of mental illness, and 40% of women from underrepresented racial and ethnic groups experience anxiety or depression during the perinatal period. People with suboptimal mental health can have poor health behaviors (e.g., poor diet, irregular sleep, low physical activity, tobacco, alcohol, and/or illicit substance use and/or difficulty adhering to medical recommendations), which can negatively impact their cardiovascular health. The mother’s mental health can also affect the child’s neurological development and well-being.

Initial Mental Health Screening Should Take Place as Early as Possible in Pregnancy

“Pregnancy is an important time in life from a health perspective. However, it is not known how many health professionals understand the connection between the mind and the heart and routinely assess and optimize mental health during the perinatal period. Mental health screening before, during, and after pregnancy should be implemented along with screening for hypertension, type 2 diabetes, and other modifiable cardiovascular risk factors,” the researchers said.

Risk factors for mental health issues include domestic violence, sleep disturbances, personal or family history of mental illness, incarceration, active military service, veteran status, lack of partner support, unemployment, and racism and discrimination. Adverse outcomes of previous pregnancies, including miscarriage, ectopic pregnancy, and high blood pressure during pregnancy, are also risk factors for perinatal anxiety and depression.

Regularly implementing mental health screening as part of perinatal care requires training healthcare professionals to effectively use screening tools and creating protocols for follow-up, including a comprehensive assessment and appropriate action. For example, the Patient Health Questionnaire (PHQ-9) can be used by healthcare professionals to screen for symptoms of depression and anxiety. This universal screening tool has been shown to be effective in raising awareness of mental health issues and reducing the stigma associated with them.

An initial mental health screen should take place as early as possible in pregnancy and repeated at least once. At the initial antenatal visit, it is important to review the patient’s mental health history and use of psychotropic medications or other treatments to identify risk factors for mental illness. Because mental symptoms can fluctuate over time, questions about emotional well-being (and, if applicable, partner well-being) should ideally be asked at each prenatal or postnatal visit.

Maternal Mental Health Treatment

Regardless of setting and circumstance, perinatal mental health care should be culturally responsive, linguistically appropriate, and family-oriented. It should involve shared decision-making with the patient (and her partner, if the patient consents), including a full discussion of the potential risks and benefits of any treatments offered to the mother and to the fetus or newborn. When considering medical treatment for depression or anxiety, the choice of medication should be based on efficacy in pregnancy, safety in pregnancy, safety during breastfeeding (if applicable), and consideration of interactions with other medications.

Because medications carry potential adverse effects for the mother and child, there is a great deal of interest in non-pharmacological strategies for preventing and treating depression and anxiety symptoms during and after pregnancy. Counseling, cognitive behavioral therapies, exercise, stress management strategies, and other treatment methods may be preferred. Healthcare professionals providing care, such as psychologists, clinical social workers, psychiatrists, general practitioners, and obstetricians, should work together as a team and have the appropriate training and skills to ensure continuity of care for patients and their families during pregnancy and after childbirth.

Future Research Needs

Known barriers to addressing perinatal mental health issues include stigma, fear of child removal by child protection services, clinicians’ lack of time, clinicians’ inexperience, staffing issues, and reimbursement issues. Healthcare models must be created that encourage healthcare systems and clinicians to adopt evidence-based, accessible models of care that focus on awareness, screening and optimizing mental health, along with partnerships with community-based organizations.

Furthermore, there is an urgent need for long-term research on perinatal mental health, as it affects cardiovascular health and other chronic disease trajectories across the lifespan. Given the well-known disparities in maternal health based on race, ethnicity, and social determinants of health, more underrepresented racial and ethnic groups need to be included in studies of maternal mental and cardiovascular health. More research is also needed on psychological factors other than depression, such as anxiety disorders, adverse childhood experiences, post-traumatic stress disorder and psychosocial stressors, which disproportionately or differentially affect women.