2025 AHA科学声明：优化围产期心理健康——更新产妇心血管健康
Figure 1. Different psychological health and cardiovascular disease conditions that should be assessed and optimized during the different pregnancy windows.
There is an emphasis on the perinatal optimization of psychological health as well as the components of cardiovascular health as framed by the AHA’s Life’s Essential 8; the psychological health icon is in the center of Life’s Essential 8. The icons depicting the pregnancy windows extending from the preconception (early life and adulthood), prenatal and postnatal, and interpregnancy periods (through 12 months postpartum) represent a continuum reflecting the need to manage these conditions throughout this time frame. The figure depicts the biological and social determinants of health underpinnings of psychological and cardiovascular health. AHA indicates American Heart Association; CVD, cardiovascular disease; CVH, cardiovascular health; and PTSD, posttraumatic stress disorder.
treatment of psychological health, including postpartum depression, anxiety, and posttraumatic stress disorder. 60–62 For example, although mood disorders are more prevalent among non-Hispanic Black, Hispanic, and Asian/Pacific Islander patients, there is a lower
prevalence of routine psychological treatment in those groups. 62 Black pregnant people are more likely to have experienced chronic stressors such as poverty, racism, and intimate partner violence. 62,63 The rates of postpartum depression are higher in rural areas. 64 Race,
ethnicity, and rurality interact because Black people, Indigenous people, Asian people, and Hispanic Black people show a higher incidence of mental health disorders when screened in rural versus urban clinics. 65 Lower treatment referral rates and more variability in the type of treatment offered were also found among patients in underrepresented racial and ethnic groups and those served by rural clinics than in comparison groups. 65,66
PERINATAL PSYCHOLOGICAL HEALTH AND ADVERSE PREGNANCY OUTCOMES
As discussed earlier, adverse psychological health is the leading cause of maternal death in the United States 67,68 and contributes to significant perinatal morbidity. 69 Several studies have analyzed the relationship between maternal psychological health and adverse pregnancy outcomes. Recent studies and a meta-analysis of extant literature have demonstrated that individuals with a history of depression have an increased risk for preeclampsia ( Table 1 ). 70–77
There are conflicting results from prior studies, likely due to differences in the measures used to assess depression, the populations studied, and which confounders were included in the multivariable adjustment. Recent studies show serotonin is dysregulated in preeclampsia, raising the question of the relationship between past selective serotonin reuptake inhibitor (SSRI) use and risk for preeclampsia. 79–83 In a recent meta-analysis, gestational SSRI use was associated with $43\%$ greater odds of preeclampsia $(95\%$ CI, 1.5– 1.78). 79 However, there were several limitations, and the findings do not suggest a causal relationship between SSRI use and preeclampsia. Additionally, 7 of 9 studies did not adjust for anxiety or depression severity, which is shown to independently increase the risk of preeclampsia. Furthermore, the data on other psychological disorders or stressors and risk of preeclampsia are limited, and the definition of psychosocial stress varied from using established scores to self-report, offering avenues to expand evidence in this area.
Although findings on the association between depression and preterm birth (ie, delivery at ${<}37$ weeks gestation) are mixed, on balance there is no convincing evidence for a link between the two ( Table 1 ). A multicenter prospective cohort study of 3432 women found no association with preterm birth and mood disorders. 75 In contrast, 2 meta-analyses demonstrated that antenatal maternal depression or depression during pregnancy was associated with preterm birth, 70,76 although this was no longer the case after additional adjustment in subanalyses, suggesting that the effect sizes might be smaller than initially expected. In several
Table 1. Associations Between Maternal Psychological Health and Adverse Pregnancy Outcomes
|Study| Study type/ population | Adjusted HR, OR, or RR (95% CI)* | |---|---|---| |Risk of preeclampsia|Risk of preeclampsia|Risk of preeclampsia| |Depression|Depression|Depression| | Grigoriadis et al 201370 |Meta-analysis|HR, 1.35 (0.95-1.92)| |Hu et al 201571|Meta-analysis|OR,1.63 (1.32-2.02)| |Raina et al 202172| Population-based cohort study/NIS |OR, 1.25 (1.10-1.42)| |Anxiety|Anxiety|Anxiety| |Raina et al 202172| Population-based cohort study/NIS |OR, 1.52 (1.44-1.60)| | Bipolar disorder||| |Raina et al 202172| Population-based cohort study/NIS |OR, 1.25 (1.14-1.38)| |Posttraumatic stress disorder||| |Shaw et al 201773| Veterans Affairs cohort study |RR, 1.3 (1.1-1.6)| |Mental stress*||| |Zhang et al 201374|Meta-analysis|OR, 1.49 (1.27-1.74)| |Work stresst||| |Zhang et al 201374|Meta-analysis|OR, 1.50 (1.15-1.97)| |Risk of preterm birth ||| |Depression|Depression|Depression| |Cripe et al 201175| Cohort study|RR, 1.56 (0.98-2.47)| | Grigoriadis et al 201370 |Meta-analysis|OR, 1.37 (1.04-1.81)| |Grote et al 201076|Meta-analysis|RR, 1.13 (1.06-1.21)| |Risk of intrauterine growth restriction ||| |Depression|Depression|| |Kim et al 201377|Cohort study|OR, 2.32 (0.96-5.58)| |Grote et al 201176|Meta-analysis|RR, 1.03 (0.99-1.08)|
HR indicates hazard ratio; NIS, National Inpatient Sample; OR, odds ratio; and RR, relative risk.
\*Mental stress is defined as the psychological feeling of strain and pressure. 74
† Work stress is defined as mental stress derived from work. 74 Adverse pregnancy outcomes are a group of disorders with shared pathogenesis such as hypertensive disorders of pregnancy, gestational diabetes, preterm birth, small for gestational age infants, and placental abruption. 78
studies, depression was not associated with intrauterine growth restriction after multivariable adjustment ( Table 1 ). 76,77
POSTPARTUM DEPRESSION AND FUTURE CARDIOVASCULAR DISEASE
Given the health risks associated with perinatal depression, 70–72,75–77 the American College of Obstetricians and Gynecologists (ACOG) recommends that all pregnant and postpartum patients be screened for depression. 84 A Swedish Medical Birth Registry study in which
55539 women who were diagnosed with perinatal depression between 2001 and 2014 were compared with another group of 545567 women without depression, found that those with perinatal and postpartum depression were $36\%$ more likely to have cardiovascular disease. 85 A study based on claims data also noted an increased risk in ischemic heart disease 24 months after perinatal depression of $83\%$ . 29 Although most evidence concerns the cardiovascular risks associated with postpartum depression, there has been less investigation of the risk of depression among those with suboptimal maternal CVH, supporting the rationale for regular depression screening through 12 months postpartum. A recent meta-analysis demonstrated that those who experience antenatal preeclampsia have an increased risk for depression in the postpartum period beyond the first 6 weeks. 86 This finding was replicated in a recent prospective cohort study demonstrating that a prior psychological health history and a history of preeclampsia was associated with higher postnatal depression scores. 87 Although further research is needed to identify the causal pathways for these associations, recommendations for cardiovascular screening and prevention during the postpartum period for patients with prenatal depression are essential. The US Preventive Services Task Force recommends interventions including counseling, health system interventions, physical activity, education, supportive interventions, and other behavioral interventions, such as infant sleep training and expressive writing. 88 Additionally, identifying and intervening on modifiable risk factors in patients who are at increased risk of postpartum depression, such as social isolation, partner support, antenatal depression, pyrexia during pregnancy, and sleep quality, might reduce postpartum depression as well. 89 Within these recommendations, the 9-item Patient Health Questionnaire is one of the most widely used screening measures and has increased awareness, aided harm reduction, and decreased stigma. 90,91
brain development, including cortical thinning, 98 altered brain microstructure, 99,100 altered amygdala, 101 and hippocampal growth, 102 and alterations in structural and functional neural networks (ie, the connectome). 103 Placental dysfunction, 104 including decreased perfusion 105 and expression of neurotropic precursors, such as 11 β -HSD2 (11- $\upbeta$ -hydroxysteroid dehydrogenase type 2), are all potential mechanisms. 106 In addition to ramifications for maternal cardiovascular risk, it is plausible that such intergenerational risk translates to increased cardiometabolic vulnerability among their offspring. 107
CONSIDERATIONS FOR SCREENING AND MANAGEMENT OF PERINATAL PSYCHOLOGICAL HEALTH
This section summarizes the recommendations from the ACOG and US Preventive Services Task Force and could be used as a resource for cardiovascular, behavioral health, and obstetric clinicians participating in the care of pregnancy-capable individuals. Screening for perinatal mental health disorders across pregnancy and postpartum is an important first step. 108 Aligning with the US Preventive Services Task Force recommendations on population-wide screening for depression and anxiety, the ACOG recommends that all pregnant people be screened using a validated instrument to promote early diagnosis and treatment of psychological conditions 84 and suggests that subsequent interventions can potentially reduce associated harm to the maternal–infant dyad and advance health equity. 109 Incorporating psychological health management into the obstetric practice is feasible, effective, and improves access to psychological care in general. 110 Providing education to patients and families about the warning signs and various health effects of perinatal mental health conditions is equally essential for prevention and early intervention. 111
INTERGENERATIONAL IMPACT OF MATERNAL PSYCHOLOGICAL HEALTH
Maternal psychological health during the perinatal period is associated with a variety of outcomes in offspring, including the offspring’s risk for resilience to mental health conditions during childhood. 92,93 Studies of psychological stress in pregnant women show associations between a mother’s perceived psychosocial stress and psychological distress with long-term child emotional, behavioral, and cognitive dysfunction. 94–97 Maternal prenatal anxiety is a key environmental exposure that has been linked to altered fetal
RISK OF PSYCHOLOGICAL DISORDERS IN THE PERINATAL PERIOD
In line with the ACOG and other professional guidelines, we suggest assessment and screening for symptoms of anxiety and depressive disorders for all birthing people across the perinatal period. This approach is critical to identify those at risk and to provide access to support and early intervention as needed. Integrating regular psychological health screening into perinatalCVH care involves training health care professionals to use screening tools effectively and establishing protocols for follow-up care, including comprehensive
assessment and appropriate interventions. By prioritizing recurrent screening, health care services can better support birthing people during this sensitive period and promote long-term health and well-being for the parent–infant dyad. Although referral and care pathways vary across settings (eg, obstetrics, primary care, cardiology) and locations (eg, urban, suburban, rural), it is important that birthing people are provided with timely access to appropriate services, ongoing psychosocial support, appropriate treatments, and resources to address SDOH.
During the initial obstetric visit, it is essential to review the psychiatric history and use of psychopharmacotherapies or other treatments and understand a patient’s history and identify risk factors for a preconception mental health condition. Finally, due to the unique stressors associated with the transition to parenthood or related to caregiving, nonbirthing parents should also be screened for psychological distress in the perinatal period to ensure each parent is monitored and offered mental health–appropriate support ( Figure 2 ).
Administration of a screening tool should be part of a multicomponent approach involving clinical judgment, clear protocols for further assessment of those who screen positive, and appropriate care pathways for regular follow-up. Initial prenatal screening should take place as early as practical in pregnancy and should be repeated at least once later in pregnancy. As psychological symptoms may fluctuate over time, inquiry about a pregnant person’s emotional wellbeing (and the well-being of their partner if appropriate) should ideally be part of every prenatal or postpartum visit. The first postnatal screening should occur 6 to 12 weeks after birth and should be repeated at least once in the first year postpartum.
Several validated screening measures can be used to detect perinatal depression and anxiety symptoms. Each is brief, easy to administer, and can be incorporated into routine prenatal and postnatal care. The Edinburgh Postnatal Depression Scale (10 items) is one of the most widely used screening tools to identify pregnant people at risk for prenatal or postpartum depression. 112 Further assessment should occur for individuals with an Edinburgh Postnatal Depression Scale score ${\geq}13$ or for those with a positive score on question 10, which screens for self-harm ideation. Other commonly used screeners are the Patient Health Questionnaire-9 (9 items), 113 which assesses severity of depressive symptoms, and the Generalized Anxiety Disorder-7 (7 items) 114 to assess the severity of generalized anxiety. The language and cultural appropriateness of each screener must be considered, and translated versions with culturally relevant cutoff scores should be used as needed.
MANAGEMENT APPROACHES TO OPTIMIZE PERINATAL PSYCHOLOGICAL HEALTH
Interventions are decided with the pregnant person and their significant other(s) based on risk–benefit analysis, which takes into consideration the benefit to the individual and the fetus or newborn, versus the potential for harm. Whatever the setting and circumstances, perinatal psychological health care should be culturally responsive, trauma-informed, and familycentered. 30 It should involve shared decision-making with the pregnant person (and their significant other[s] if the patient agrees), including a full discussion of the potential risks and benefits of any treatments offered. Health professionals providing care, such as psychologists, psychiatrists, general internal medicine specialists, and obstetricians, should work as a team in the uptitration and adjustment of the recommendations below. These clinicians should have appropriate training and skills and should work collaboratively to provide continuity of care for pregnant people and their families. Although the interventions are at the individual and hospital level, the writing group recognizes the importance of community health centers and home visiting programs, community health workers, and doulas as essential societal components of the care delivery.
PHARMACOLOGIC INTERVENTIONS
The ACOG recommends that treatment for perinatal depression be accessible to all patients. Untreated prenatal depression may lead to suicidal ideation, poor nutrition, weight loss, poor self-care, cognitive impairment, and disengagement from prenatal care 115 ; however, various interventions need to be considered in the context of effects on the mother–infant dyad. It is unclear if antidepressants, a mainstay of treatment during pregnancy, are associated with preterm birth and possible teratogenicity. 116–118 If considering pharmacologic treatment, the choice of medication should be based on whether the efficacy is known, the safety in pregnancy and during breastfeeding, and consideration of drug interactions.
SSRIs are considered first-line agents commonly used in pregnancy and postpartum. 119 SSRIs have not been associated with congenital anomalies in large studies. 120 Serotonin-norepinephrine reuptake inhibitors may be considered for patients who are unresponsive to SSRIs. For patients who have been treated effectively with an antidepressant in the past, that medication should generally be the drug of choice during pregnancy. Antidepressants should be used at the lowest effective dose and as a single agent if possible. 121
 Figure 2. Care pathway for incorporating psychological health screening and management into the AHA’s Life’s Essential
8 framework.
The figure provides a stepwise, interdisciplinary approach to screening for psychological health using validated screening tools, optimizing psychological health care with pharmacological and behavioral options, and streamlining care delivery for those with suboptimal psychological health and CVH across the preconception, antepartum, postpartum, and parenthood timeframe. It focuses on the screening and management of psychological health and CVH during these periods. The Edinburgh Postnatal Depression Scale and Patient Health Questionnaire-9, which assess the severity of depressive symptoms, and the Generalized Anxiety Disorder-7 can be used to assess psychological health. Addressing CVH and referring patients to cardio-obstetrics, family medicine, internal medicine, and behavioral health clinicians, ideally during the preconception time frame, is suggested. The figure depicts the continuation of these services during pregnancy and in the postpartum period. ACOG indicates American College of Obstetricians and Gynecologists; AHA, American Heart Association; ASA, aspirin; CVH, cardiovascular health; OB, obstetrician; and PPD, postpartum depression.
Currently, there are 2 Food and Drug Administration– approved medications for new-onset moderate to severe depression, with onset in the third trimester or within 4weeks postpartum. Brexanolone is a neurosteroid that acts on gamma-aminobutyric acid type A (GABA-A) receptors and is administered as an IV infusion over 60 hours, and zuranolone is an oral formulation dosed at 50 mg/d for 14 days. 121,122 Tricyclic antidepressants may be used in patients who are refractory to other medications listed above. This group of medications has low teratogenic potential and low excretion in breast milk, except for clomipramine; however, use is limited to select cases due to side effects of
orthostatic hypotension and anticholinergic properties. Benzodiazepines should be avoided in pregnancy. An overview of the commonly used medications is shown in Table 2 .
More recent data demonstrate that psychological interventions can prevent postpartum depression in high-risk patients. 88 The ACOG recommends that pharmacotherapy for postpartum depression not be withheld or discontinued in pregnant and lactating people alone. The ACOG recommends that SSRIs be considered as first-line pharmacotherapy and that brexanolone administration be considered for moderate to severe postpartum depression. 121,123
Table 2. Pharmacologic Therapy for Depression and Anxiety in Pregnancy and Postpartum
| Medications|Route/dose|Features|Breastfeeding| |---|---|---|---| |First-line medications|||| |Sertaline|Oral/25-200 mg| Initial medication to start. It is well tolerated. Not expected to increase risk for congenital anomalies. It was associated with neonatal pulmonary hypertension in some studies. | Lowest levels in breast milk. | | Citalopram|Oral/20-40 mg| QTc prolongation. Third-trimester use can cause transient neonatal syndrome of central nervous system and motor, respiratory, and gastrointestinal signs. || |Escitalopram| Oral/10-20 mg| QTc prolongation. Third-trimester use can cause transient neonatal syndrome of central nervous system and motor, respiratory, and gastrointestinal signs. || |Fluoxetine|Oral/20-80 mg| Long half-life. Third-trimester use can cause transient neonatal syndrome of central nervous system and motor, respiratory, and gastrointestinal signs. | Higher levels in breast milk | |Second-line medications|||| |Duloxetine|Oral/30-120 mg| Need for higher dose in third trimester. No increased risk for congenital anomalies. || |Venlafaxine|Oral/75-300 mg|No increased risk for congenital anomalies.|| |Paroxetine|Oral/20-60 mg| Need for higher dose in third trimester. First-trimester use may be associated with fetal cardiac defects; studies are inconclusive. Third-trimester use can cause transient neonatal syndrome of central nervous system and motor, respiratory, and gastrointestinal signs. || |Mirtazapine|Oral/15-45 mg| Antinausea effects. No increased risk for congenital anomalies.|| |Bupropion hydrochloride|Oral/300-450 mg| Human studies have been inconsistent with respect to risk for fetal heart defects. || | Food and Drug Administration-approved medications for late pregnancy and postpartum period|||| |Brexanolone|IV infusion of 60 h | Quick onset of action in 1-2 d lasting 30 d. No increased risk for congenital anomalies. || |Zuranolone| Oral/50 mg daily × 14 d| Significant improvement in 15 d. No increased risk for congenital anomalies. ||
There is differential access to these pharmacological interventions in certain populations due to social determinants of health. QTc indicates corrected QT interval. \*Low amount in breast milk. 121 † Paroxetine is the medication most associated with transient neonatal syndrome.
PSYCHOLOGICAL AND BEHAVIORAL INTERVENTIONS
Because medications carry potential side effects to both mother and child, there is significant interest in nonpharmacological strategies to both prevent and treat depression and anxiety symptoms during pregnancy. Current pharmacologic therapies cross the placental and blood–brain barriers and can be found in amniotic fluid 124–127 and breast milk. 128 Thus, nonpharmacologic interventions, such as cognitive behavioral therapies, electroconvulsive therapy, exercise and stress management, and other treatment paradigms, may be preferred. Although the heterogeneity among these treatments has made rigorous study comparisons difficult, preventive therapy for individuals considered at high risk for mental health disorders may improve psychological well-being and maternal motivation, enhancing physical health status and quality of life. 129–131 Interventions can be provided by behavioral
health professionals, trained therapists, or home health visitors, depending on the patient’s needs, psychological health concerns, preferences, and available resources ( Table 3 ). 132
CHALLENGES AND OPPORTUNITIES IN ADDRESSING PSYCHOLOGICAL HEALTH
Barriers to integrating perinatal psychological health care into CVH care exist at individual, health system, community level, and government and policy levels along the perinatal care continuum. 141,142 Known barriers include stigma 143–146 ; fears related to child removal 147 ; clinician time constraints 148 ; clinician inexperience addressing perinatal mental health concerns 149 ; absence of standardized screening 150 and treatment protocols in nonobstetric specialty settings;
Table 3. Psychological and Behavioral Interventions for Management of Psychological Health
|| Interpersonal psychotherapy, a structured, time-limited form of psychotherapy focused on improving interpersonal relationships to help reduce psychological symptoms.132 | |---|---| | Psychotherapy (may be effective in conjunction with, or as an alternative to, pharmacologic treatment).133 || | Psychotherapy (may be effective in conjunction with, or as an alternative to, pharmacologic treatment).133 |CBT, focused on identifying and modifying maladaptive thinking patterns, behaviors, and emotional responses.| | Psychotherapy (may be effective in conjunction with, or as an alternative to, pharmacologic treatment).133 |Acceptance and commitment therapy, a CBT approach emphasizing psychological flexibility.| | Psychotherapy (may be effective in conjunction with, or as an alternative to, pharmacologic treatment).133 | Dialectical behavioral therapy, which has similarities to CBT and focuses on mindfulness training, distress tolerance, interpersonal effectiveness, and emotion regulation. | | Psychotherapy (may be effective in conjunction with, or as an alternative to, pharmacologic treatment).133 || || Stress management and mindfulness-based interventions, which include meditation and relaxation techniques. Physical activity and exercise interventions, particularly during the prenatal period, although more evidence is needed for postpartum.134.135 | || Light therapy, nutrition-based protocols, acupuncture, massage, stress management, and mindfulness-based meditation programs have also shown some promise as both primary and adjunctive measures.132 Studies have been small, and | || programs have also shown some promise as both primary and adjunctive measures.132 Studies have been small, and results are mixed; however, in many cases, combining an alternative treatment with more conventional psychotherapy mayresults are mixed; however, in many cases, combining an alternative treatment with more conventional psychotherapy may be an attractive option to medication or ECT. Similarly, lifestyle modifications, such as optimizing diet, exercise, and sleepbe an attractive option to medication or ECT. Similarly, lifestyle modifications, such as optimizing diet, exercise, and sleep habits, while working to promote relaxation, are important strategies that can help maximize the effect of treatment. | ||| || ECT: For more severe cases of postpartum depression, and in the right clinical settings, ECT appears to be favorable to| || the use of psychotropic medications.136 In these cases, ECT is supported by ACOG.137 When considering reviews totaling >1000 pregnant patients, it has been shown to be quite effective, with a low risk of complications that most commonly include decreased fetal heart rate, contractions, and premature labor.138-140 Fetal demise is rarely reported140; therefore, reducing risk by performing a pretreatment pelvic exam, avoiding anticholinergic medications, using uterine tonometry, and administering intravenous hydration should be considered.138 The practice is supported by ACOG137 and is shown in |
ACOG indicates American College of Obstetricians and Gynecologists; CBT, cognitive behavioral therapy; and ECT; electroconvulsive therapy.
limited opportunities for training in and networks for referral to experts in women’s cardiovascular medicine, behavioral medicine, perinatal psychiatry, and psychology; workforce issues; and reimbursementrelated concerns. 151
Although some states have passed legislation to improve perinatal mental health screening, 152 many gaps in care beyond screening are evident, 150 necessitating additional support and guidance for frontline clinicians (eg, obstetricians, advanced practice clinicians, family practice physicians, internists, psychiatrists, psychologists, and cardiologists). Still, several key resources to address perinatal psychological health are available ( Table 4 ).
Multidisciplinary research efforts are pivotal to understanding the equitable implementation of these programs, 161 and lived experience 162 and communitybased expertise are crucial to relevant implementation and research on care pathways for perinatal patients with mental health challenges and CVH. 163–166 Additionally, there is a need to include communitybased initiatives and test models for delivering maternity care that could improve outcomes and reduce racial inequities such as expanding reimbursement for doulas, midwives, and community health workers. Incentivizing health systems and clinicians to adopt evidence-based, equity-centered models of care focused on awareness, screening, and optimization of psychological health with partnerships with local churches, salons, and community-based organizations
representing the population will be crucial. The writing group also recognizes the invaluable partnership between patients and health care professionals to advance care delivery and clinical trial enrollment. In addition to being mother-centered, context driven, and grounded in lived experiences, this requires a transformative approach toward health promotion such as use of social media campaigns and social networking to improve enrollment in comparative effectiveness clinical trials on pharmacological, nonpharmacological, and CVH interventions.
There is a critical need for longitudinal, prospective research on perinatal psychological health, because it influences CVH and other chronic disease outcomes across the lifespan, using frameworks such as life course theory 167,168 or the National Institute of Minority Health and Health Disparities framework adapted for mental health, areas that are largely underexplored. 169 Most significantly, reimbursement for integrated cardiovascular care, which incorporates perinatal psychologists and other behavioral health specialists, health system–community care partnerships, iterative care coordination, and collaborative care, 170 is requisite to enhance and sustain growing state and national supports for perinatal psychological health. Psychological health concerns often cooccur with substance use. Although substance use and perinatal cardiovascular outcomes are outside the purview of the article, all substances (eg, amphetamine/methamphetamine, cocaine, opioid, cannabis,
Table 4. Local and National Resources for Addressing Psychological Health
|Resources|Services| |---|---| |Postpartum Support International|They help patients and clinicians identify specialists with competencies in caring for patients with suboptimal| | PolicyCenterforMaternal Mental Health |psychological health.| | Maternal Mental Health NOw153 National Maternal Mental Health Hotline154 | The hotline (1-833-TLC-MAMA) is free and available 24/7 and includes counselors, local support groups, and organizations. This is operated by the Human Resources and Services Administration. | ||| | Perinatal Access Programs155156 Perinatal Psychiatric Consult Line157 Lifeline for Moms158 | They provide support for frontline clinicians in the management of people with suboptimal psychological health. Access programs can implement up to 5 program components, including telephone consultation with a | || health. Access programs can implement up to 5 program components, including telephone consultation with a perinatal psychiatry expert, 1-time patient-facing consultation with a perinatal psychiatry expert, resource and referral to perinatal professionals or patients, training for perinatal professionals, and practice-level technical | | VeteransAffairsReproductiveMental Health Consultation Program159.160 | referral to perinatal professionals or patients, training for perinatal professionals, and practice-level technical assistance. |
and alcohol) are associated with an increased risk of acute cardiovascular events. 171 This highlights the need for increased surveillance of pregnant women with substance use.
Despite recent state and national attention to maternal psychological health, related science is still too often siloed from investigations of maternal CVH. Thus, there are many opportunities to integrate and advance this work to the advantage of all women of childbearing age and the future generations they support. First, individual psychological factors are often measured and evaluated in isolation rather than examining multiple factors concurrently, such as several indicators of psychosocial stress, to better understand their interactions and identify subgroups of women with the greatest associated cardiovascular risk and opportunities for timely interventions. Second, most evidence has concerned depression and CVH, and increased research is needed related to other psychological factors (eg, anxiety, adverse childhood experiences, posttraumatic stress disorder, which are psychosocial stressors that disproportionately or differentially affect women). 45,172 Third, despite known disparities in maternal health based on race, ethnicity, and SDOH, women who belong to underrepresented racial or ethnic groups or socioeconomically disadvantaged groups are less likely to be represented in studies on maternal psychological health and CVH, and investigators frequently neglect to disaggregate associations by these vulnerable subgroups to examine if associations are more pronounced among some women versus others. Fourth, although psychological symptoms fluctuate over time, particularly in response to the events of pregnancy, investigations of psychological and maternal CVH are often limited to certain time points in the perinatal period (eg, prenatal or postpartum) rather than reflecting the entire perinatal period. Finally, significantly greater funding must
be directed toward clinical trials of psychological and behavioral interventions to prevent or treat perinatal psychological health, and to prevent subsequent consequences for the mother–infant dyad and ensure the future health and well-being of the child. Thus, there is considerable motivation to advance the evidence reflecting maternal psychological CVH and to dually offer more patient-centered and more equitable maternal care.
ARTICLE INFORMATION
The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on December 11, 2024, and the American Heart Association Executive Committee on January 16, 2025. A copy of the document is available at https://professional.heart.org/state ments by using either “Search for Guidelines & Statements” or the “Browse by Topic” area.
The American Heart Association requests that this document be cited as follows: Sharma G, Gaffey AE, Hameed A, Kasparian NA, Mauricio R, Breese Marsh E, Beck D, Skowronski J, Wolfe D, Levine GN; on behalf of the American Heart Association Women’s Health Science Committee of the Council on Clinical Cardiology and the Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Surgery and Anesthesia; Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Lifestyle and Cardiometabolic Health; and Council on Quality of Care and Outcomes Research. Optimizing psychological health across the perinatal period: an update on maternal cardiovascular health: a scientific statement from the American Heart Association. J Am Heart Assoc . 2025;13:e041369. doi: 10.1161/JAHA.125.041369 .
The expert peer review of AHA-commissioned documents (eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit https://professional.heart.org/statements . Select the “Guidelines & Statements” drop-down menu, then click “Publication Development.”
Disclosures
Writing Group Disclosures
| Writing group member |Employment| Research grant| Other research support | Speakers' bureau/ honoraria | Expert witness | Ownership interest | Consultant/ advisory board |Other| |---|---|---|---|---|---|---|---|---| | Garima Sharma| Inova Heart and Vascular Institute | American Heart Association (HRSN 979642)* |None|None|None|None|None|None| | Glenn N. Levine | Baylor College of Medicine |None|None|None|None|None|INone|None| |Dana Beck| University of California at Los Angeles School of Nursing |None|None|None|None|None|None|None| | Allison E. Gaffey | Yale School of Medicine; Veterans Affairs Connecticut Healthcare System | National Institutes of Health/National Heart, Lung, and Blood Institute (K23HL168233)* |None|None|None|None|INone|None| | Afshan Hameed | University of California, Irvine Medical Center |None|None|None|None|None|None|None| | Nadine A. Kasparian | Cincinnati Children's Hospital, Medical Center, Heart Institute, Heart and Mind Wellbeing Center | National Institutes of Health (National Heart, Lung, and Blood Institute UM1)*; The Brett Boyer Foundation (discovery grant)*; Additional Ventures (Single Ventricle Research Fund)*; American Heart Association (Visiting Professorship Award)* (There is no conflict of interest for any of the above.) |None|None|None|None|None|None| | Elisabeth Breese Marsh | Johns Hopkins School of Medicine |None|None|None|None|INone|None|None| | Rina Mauricio| University of Texas Southwestern |None|None|None|None|None|None|None| | Jenna Skowronski | University of Pittsburgh Medical Center |None|None|None|None|None|INone|None| |Diana Wolfe| Albert Einstein College of Medicine |None|None|None|INone|None|INone|None|
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflictsof interestas reportedon the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (1) the person receives $\S5000$ or more during any 12-month period, or $5\%$ or more of the person’s gross income; or (2) the person owns $5\%$ or more of the voting stock or share of the entity, or owns $\S5000$ or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition. \* Significant.
Reviewer Disclosures
|Reviewer| Employment |Research grant| Other research support | Speakers' bureau/ honoraria | Expert witness | Ownership interest | Consultant/ advisory board |Other| |---|---|---|---|---|---|---|---|---| | LaPrincess C.Brewer | Mayo Clinic, Department of Cardiovascular Medicine |INone|None|None|None|None|INone|None| |Emily Lau| Massachusetts General Hospital |None|None|None|None|None|INone|None| | Jennifer Lewey | University of Pennsylvania |INone|None|INone|None|None|INone|None| | Shiv Darius Tandon | Northwestern University Feinberg School of Medicine | National Institutes of Health/National Heart, Lung, and Blood Institute (Intervention is focused on cardiovascular health in the perinatal period, which includes a focus on psychological health.)* |None|None|None|None|None|None| | Sammy Zakaria | Johns Hopkins University School of Medicine |None|None|None|None|None|INone|None|
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (1) the person receives $\S5000$ or more during any 12-month period, or $5\%$ or more of the person’s gross income; or (2) the person owns $5\%$ or more of the voting stock or share of the entity, or owns $\S5000$ or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition. \* Modest.
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| Study | Study type/ population | Adjusted HR, OR, or RR (95% CI)* |
|---|---|---|
| Risk of preeclampsia | Risk of preeclampsia | Risk of preeclampsia |
| Depression | Depression | Depression |
| Grigoriadis et al 201370 | Meta-analysis | HR, 1.35 (0.95-1.92) |
| Hu et al 201571 | Meta-analysis | OR,1.63 (1.32-2.02) |
| Raina et al 202172 | Population-based cohort study/NIS | OR, 1.25 (1.10-1.42) |
| Anxiety | Anxiety | Anxiety |
| Raina et al 202172 | Population-based cohort study/NIS | OR, 1.52 (1.44-1.60) |
| Bipolar disorder | ||
| Raina et al 202172 | Population-based cohort study/NIS | OR, 1.25 (1.14-1.38) |
| Posttraumatic stress disorder | ||
| Shaw et al 201773 | Veterans Affairs cohort study | RR, 1.3 (1.1-1.6) |
| Mental stress* | ||
| Zhang et al 201374 | Meta-analysis | OR, 1.49 (1.27-1.74) |
| Work stresst | ||
| Zhang et al 201374 | Meta-analysis | OR, 1.50 (1.15-1.97) |
| Risk of preterm birth | ||
| Depression | Depression | Depression |
| Cripe et al 201175 | Cohort study | RR, 1.56 (0.98-2.47) |
| Grigoriadis et al 201370 | Meta-analysis | OR, 1.37 (1.04-1.81) |
| Grote et al 201076 | Meta-analysis | RR, 1.13 (1.06-1.21) |
| Risk of intrauterine growth restriction | ||
| Depression | Depression | |
| Kim et al 201377 | Cohort study | OR, 2.32 (0.96-5.58) |
| Grote et al 201176 | Meta-analysis | RR, 1.03 (0.99-1.08) |
| Medications | Route/dose | Features | Breastfeeding |
|---|---|---|---|
| First-line medications | |||
| Sertaline | Oral/25-200 mg | Initial medication to start. It is well tolerated. Not expected to increase risk for congenital anomalies. It was associated with neonatal pulmonary hypertension in some studies. | Lowest levels in breast milk. |
| Citalopram | Oral/20-40 mg | QTc prolongation. Third-trimester use can cause transient neonatal syndrome of central nervous system and motor, respiratory, and gastrointestinal signs. | |
| Escitalopram | Oral/10-20 mg | QTc prolongation. Third-trimester use can cause transient neonatal syndrome of central nervous system and motor, respiratory, and gastrointestinal signs. | |
| Fluoxetine | Oral/20-80 mg | Long half-life. Third-trimester use can cause transient neonatal syndrome of central nervous system and motor, respiratory, and gastrointestinal signs. | Higher levels in breast milk |
| Second-line medications | |||
| Duloxetine | Oral/30-120 mg | Need for higher dose in third trimester. No increased risk for congenital anomalies. | |
| Venlafaxine | Oral/75-300 mg | No increased risk for congenital anomalies. | |
| Paroxetine | Oral/20-60 mg | Need for higher dose in third trimester. First-trimester use may be associated with fetal cardiac defects; studies are inconclusive. Third-trimester use can cause transient neonatal syndrome of central nervous system and motor, respiratory, and gastrointestinal signs. | |
| Mirtazapine | Oral/15-45 mg | Antinausea effects. No increased risk for congenital anomalies. | |
| Bupropion hydrochloride | Oral/300-450 mg | Human studies have been inconsistent with respect to risk for fetal heart defects. | |
| Food and Drug Administration-approved medications for late pregnancy and postpartum period | |||
| Brexanolone | IV infusion of 60 h | Quick onset of action in 1-2 d lasting 30 d. No increased risk for congenital anomalies. | |
| Zuranolone | Oral/50 mg daily × 14 d | Significant improvement in 15 d. No increased risk for congenital anomalies. |
| Interpersonal psychotherapy, a structured, time-limited form of psychotherapy focused on improving interpersonal relationships to help reduce psychological symptoms.132 | |
|---|---|
| Psychotherapy (may be effective in conjunction with, or as an alternative to, pharmacologic treatment).133 | |
| Psychotherapy (may be effective in conjunction with, or as an alternative to, pharmacologic treatment).133 | CBT, focused on identifying and modifying maladaptive thinking patterns, behaviors, and emotional responses. |
| Psychotherapy (may be effective in conjunction with, or as an alternative to, pharmacologic treatment).133 | Acceptance and commitment therapy, a CBT approach emphasizing psychological flexibility. |
| Psychotherapy (may be effective in conjunction with, or as an alternative to, pharmacologic treatment).133 | Dialectical behavioral therapy, which has similarities to CBT and focuses on mindfulness training, distress tolerance, interpersonal effectiveness, and emotion regulation. |
| Psychotherapy (may be effective in conjunction with, or as an alternative to, pharmacologic treatment).133 | |
| Stress management and mindfulness-based interventions, which include meditation and relaxation techniques. Physical activity and exercise interventions, particularly during the prenatal period, although more evidence is needed for postpartum.134.135 | |
| Light therapy, nutrition-based protocols, acupuncture, massage, stress management, and mindfulness-based meditation programs have also shown some promise as both primary and adjunctive measures.132 Studies have been small, and | |
| programs have also shown some promise as both primary and adjunctive measures.132 Studies have been small, and results are mixed; however, in many cases, combining an alternative treatment with more conventional psychotherapy mayresults are mixed; however, in many cases, combining an alternative treatment with more conventional psychotherapy may be an attractive option to medication or ECT. Similarly, lifestyle modifications, such as optimizing diet, exercise, and sleepbe an attractive option to medication or ECT. Similarly, lifestyle modifications, such as optimizing diet, exercise, and sleep habits, while working to promote relaxation, are important strategies that can help maximize the effect of treatment. | |
| ECT: For more severe cases of postpartum depression, and in the right clinical settings, ECT appears to be favorable to | |
| the use of psychotropic medications.136 In these cases, ECT is supported by ACOG.137 When considering reviews totaling >1000 pregnant patients, it has been shown to be quite effective, with a low risk of complications that most commonly include decreased fetal heart rate, contractions, and premature labor.138-140 Fetal demise is rarely reported140; therefore, reducing risk by performing a pretreatment pelvic exam, avoiding anticholinergic medications, using uterine tonometry, and administering intravenous hydration should be considered.138 The practice is supported by ACOG137 and is shown in |
| Resources | Services |
|---|---|
| Postpartum Support International | They help patients and clinicians identify specialists with competencies in caring for patients with suboptimal |
| PolicyCenterforMaternal Mental Health | psychological health. |
| Maternal Mental Health NOw153 National Maternal Mental Health Hotline154 | The hotline (1-833-TLC-MAMA) is free and available 24/7 and includes counselors, local support groups, and organizations. This is operated by the Human Resources and Services Administration. |
| Perinatal Access Programs155156 Perinatal Psychiatric Consult Line157 Lifeline for Moms158 | They provide support for frontline clinicians in the management of people with suboptimal psychological health. Access programs can implement up to 5 program components, including telephone consultation with a |
| health. Access programs can implement up to 5 program components, including telephone consultation with a perinatal psychiatry expert, 1-time patient-facing consultation with a perinatal psychiatry expert, resource and referral to perinatal professionals or patients, training for perinatal professionals, and practice-level technical | |
| VeteransAffairsReproductiveMental Health Consultation Program159.160 | referral to perinatal professionals or patients, training for perinatal professionals, and practice-level technical assistance. |
| Writing group member | Employment | Research grant | Other research support | Speakers' bureau/ honoraria | Expert witness | Ownership interest | Consultant/ advisory board | Other |
|---|---|---|---|---|---|---|---|---|
| Garima Sharma | Inova Heart and Vascular Institute | American Heart Association (HRSN 979642)* | None | None | None | None | None | None |
| Glenn N. Levine | Baylor College of Medicine | None | None | None | None | None | INone | None |
| Dana Beck | University of California at Los Angeles School of Nursing | None | None | None | None | None | None | None |
| Allison E. Gaffey | Yale School of Medicine; Veterans Affairs Connecticut Healthcare System | National Institutes of Health/National Heart, Lung, and Blood Institute (K23HL168233)* | None | None | None | None | INone | None |
| Afshan Hameed | University of California, Irvine Medical Center | None | None | None | None | None | None | None |
| Nadine A. Kasparian | Cincinnati Children's Hospital, Medical Center, Heart Institute, Heart and Mind Wellbeing Center | National Institutes of Health (National Heart, Lung, and Blood Institute UM1)*; The Brett Boyer Foundation (discovery grant)*; Additional Ventures (Single Ventricle Research Fund)*; American Heart Association (Visiting Professorship Award)* (There is no conflict of interest for any of the above.) | None | None | None | None | None | None |
| Elisabeth Breese Marsh | Johns Hopkins School of Medicine | None | None | None | None | INone | None | None |
| Rina Mauricio | University of Texas Southwestern | None | None | None | None | None | None | None |
| Jenna Skowronski | University of Pittsburgh Medical Center | None | None | None | None | None | INone | None |
| Diana Wolfe | Albert Einstein College of Medicine | None | None | None | INone | None | INone | None |
| Reviewer | Employment | Research grant | Other research support | Speakers' bureau/ honoraria | Expert witness | Ownership interest | Consultant/ advisory board | Other |
|---|---|---|---|---|---|---|---|---|
| LaPrincess C.Brewer | Mayo Clinic, Department of Cardiovascular Medicine | INone | None | None | None | None | INone | None |
| Emily Lau | Massachusetts General Hospital | None | None | None | None | None | INone | None |
| Jennifer Lewey | University of Pennsylvania | INone | None | INone | None | None | INone | None |
| Shiv Darius Tandon | Northwestern University Feinberg School of Medicine | National Institutes of Health/National Heart, Lung, and Blood Institute (Intervention is focused on cardiovascular health in the perinatal period, which includes a focus on psychological health.)* | None | None | None | None | None | None |
| Sammy Zakaria | Johns Hopkins University School of Medicine | None | None | None | None | None | INone | None |
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引用 / 出处
2025 AHA科学声明：优化围产期心理健康——更新产妇心血管健康. 2025.