Cardiology · Advanced Heart Failure & TransplantationUniversity of North Carolina at Chapel HilljennasChapel Hill, NC, USA
Overview
Optimizing Psychological Health Across the Perinatal Period: An Update on Maternal Cardiovascular Health: A Scientific Statement From the American Heart Association.
Feb 25, 2025DOI: 10.1161/jaha.125.041369Journal ArticleAHA
Written by: Garima SharmaAllison E GaffeyAfshan HameedNadine A KasparianRina MauricioElisabeth Breese MarshDana BeckJenna SkowronskiDiana WolfeGlenn N LevineAmerican 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
PREVALENCE OF PSYCHOLOGICAL HEALTH DISORDERS DURING THE PERINATAL PERIOD
This section will focus on the overall prevalence, associated comorbidities, and risk factors of psychological health disorders.An estimated 52% of pregnancy‐capable individuals report a history of a psychological health disorder,23 and 40% of those from historically underrepresented populations present with anxiety or depression in the perinatal period.24 Individuals who endure diverse psychosocial exposures (eg, adverse childhood experiences, physical abuse and trauma in adulthood, intimate partner violence, chronic stress due to sex roles, occupation, or social circumstances, and with related psychological symptoms and conditions such as past or current depression, anxiety, or posttraumatic stress disorder) show a distinct risk for cardiovascular complications, adverse pregnancy outcomes such as preeclampsia/eclampsia, gestational diabetes, preterm birth, and small for gestational age infants, and for postpartum cardiovascular disease compared with those without such exposures, symptoms, or conditions.25, 26, 27, 28, 29, 30 A meta‐analysis of 61.2 million pregnancies showed birthing individuals with clinically significant symptoms of depression or anxiety, or a medical record diagnosis of an anxiety or depressive disorder, had a 39% greater risk of hypertensive disorders of pregnancy compared with women without such a history.27 When analyses were limited to prepregnancy anxiety or depression, there was still an association between poor psychological health and risk of hypertension.27 Findings from another study of 119 422 pregnancies documented in the Maine Health Data Organization's All Payer Claims Data indicated prenatal depression was associated with an 83% increased risk of ischemic heart disease.29 Because psychological health and CVH are recurrently associated throughout the perinatal period, it is essential to prioritize investigation of psychological health as part of maternal CVH to clarify how and when adverse psychological experiences affect CVH.18Risk factors for suboptimal psychological health include domestic violence, sleep disorders, personal or family history of psychological conditions, incarceration, younger age, active‐duty military service, veteran status, lack of partner support, unemployment, and social drivers of health resulting from systemic racism and discrimination.31, 32, 33, 34, 35, 36, 37 For example, people with both a personal and family history of depression or anxiety have a 2‐fold greater risk of prenatal depression compared with those without such a history.32, 38 A history of psychiatric treatment during a prior pregnancy or at another time is an established risk factor for perinatal depression.33, 34, 35 Adverse obstetric outcomes in prior pregnancies, including prior miscarriage, adverse pregnancy outcomes, especially preeclampsia, ectopic pregnancy, and unplanned or unwanted pregnancy are also risk factors for perinatal anxiety and depression.39
ASSOCIATIONS BETWEEN PSYCHOLOGICAL HEALTH AND SOCIAL DETERMINANTS OF HEALTH
Social determinants of health (SDOH), also referred to as social drivers of health, are the social and material circumstances into which individuals are born, and then live, work, and age (eg, education, health care access, income, neighborhood safety, social connectivity, and discrimination).40 These factors are interconnected with psychological health and foundational to CVH.40 Results from a systematic review of 83 studies suggested race and ethnicity, insurance, and education, and underpinnings of structural racism may have the greatest effects on maternal morbidity.41, 42
Despite the well‐known connections between SDOH and psychological health, there is a paucity of research reflecting this interaction in relation to maternal CVH. In a cross‐sectional examination of pregnant individuals aged 18 to 49 years, over half of women who had the greatest SDOH burden also showed suboptimal CVH.43 In a study from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers‐to‐Be cohort,44 birthing individuals were categorized by exposure to psychosocial stressors (ie, based on psychological and sociocultural indices). Using latent class analysis, it was determined that individuals in the most disadvantaged psychosocial class had a 2‐fold greater risk of suboptimal CVH (ie, ≥2 Life's Essential 8 risk factors) than those in the most advantaged class.44 Among pregnancy‐capable individuals, beneath the umbrella of SDOH, a complex interplay of behavioral and physiological pathways links psychological health with cardiovascular outcomes (Figure 1).45
First, individuals with suboptimal psychological health may also engage in suboptimal health behaviors (eg, poor diet, irregular sleep, low physical activity, illicit substance use, difficulty adhering to medical recommendations), which can significantly alter their CVH.46, 47 Those with suboptimal psychological health also show distinct patterns of sympathetic nervous system, neuroendocrine, metabolic, or immune system activity, which then elevates cardiometabolic risk in themselves and their offspring.48, 49 Proposed mechanisms of psychological–maternal CVH associations include elevated inflammatory cytokines and diurnal cortisol, a decreased cortisol awakening response,28, 47, 50 autonomic dysfunction,50, 51 increased platelet reactivity,51 and impaired endothelial function.46 The theory of allostatic load is often used to explain the aggregate biological effects of suboptimal psychological health on CVH,52 but the model can be controversial due to considerable variability in the biomarkers measured and in how those data are aggregated.53 Chronic stress and posttraumatic stress disorder are also associated with intergenerational adverse health outcomes, including elevated or blunted maternal cortisol levels, increased rate of preterm birth, low birth weight, and potential epigenetic changes in offspring.54, 55, 56, 57, 58, 59 To better understand the impact of psychological health and the optimal timing for relevant psychological intervention, further multisystemic studies are needed to adequately identify the candidate mechanisms underlying psychological–CVH associations influential within maternal health and with potential intergenerational consequences.
Importantly, racial and ethnic disparities are consistently observed in the incidence, screening, and treatment of psychological health, including postpartum depression, anxiety, and posttraumatic stress disorder.60, 61, 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 States67, 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, 71, 72, 73, 74, 75, 76, 77
Associations Between Maternal Psychological Health and Adverse Pregnancy Outcomes
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
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, 80, 81, 82, 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 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, 71, 72, 75, 76, 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 55 539 women who were diagnosed with perinatal depression between 2001 and 2014 were compared with another group of 545 567 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
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, 95, 96, 97 Maternal prenatal anxiety is a key environmental exposure that has been linked to altered fetal 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 perfusion105 and expression of neurotropic precursors, such as 11β‐HSD2 (11‐β‐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 conditions84 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
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 perinatal‐CVH 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 well‐being (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 ≥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 family‐centered.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 care115; 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, 117, 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
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 4 weeks 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.
Pharmacologic Therapy for Depression and Anxiety in Pregnancy and Postpartum
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.
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.
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
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 fluid124, 125, 126, 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, 130, 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
Psychological and Behavioral Interventions for Management of Psychological Health
ACOG indicates American College of Obstetricians and Gynecologists; CBT, cognitive behavioral therapy; and ECT; electroconvulsive therapy.
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 stigma143, 144, 145, 146; fears related to child removal147; clinician time constraints148; clinician inexperience addressing perinatal mental health concerns149; absence of standardized screening150 and treatment protocols in nonobstetric specialty settings; 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 reimbursement‐related 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).
Local and National Resources for Addressing Psychological Health
Postpartum Support International
Policy Center for Maternal Mental Health
Maternal Mental Health NOW153
National Maternal Mental Health Hotline154
They help patients and clinicians identify specialists with competencies in caring for patients with suboptimal psychological health.
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 Programs155, 156
Perinatal Psychiatric Consult Line157
Lifeline for Moms158
Veterans Affairs Reproductive Mental Health Consultation Program159, 160
Multidisciplinary research efforts are pivotal to understanding the equitable implementation of these programs,161 and lived experience162 and community‐based expertise are crucial to relevant implementation and research on care pathways for perinatal patients with mental health challenges and CVH.163, 164, 165, 166 Additionally, there is a need to include community‐based 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 theory167, 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 co‐occur 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, 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 ma‐ternal care.
Writing Group Disclosures
Writing group memberEmploymentResearch grantOther research supportSpeakers' bureau/honorariaExpert witnessOwnership interestConsultant/advisory boardOtherGarima SharmaInova Heart and Vascular InstituteAmerican Heart Association (HRSN 979642)NoneNoneNoneNoneNoneNoneGlenn N. LevineBaylor College of MedicineNoneNoneNoneNoneNoneNoneNoneDana BeckUniversity of California at Los Angeles School of NursingNoneNoneNoneNoneNoneNoneNoneAllison E. GaffeyYale School of Medicine; Veterans Affairs Connecticut Healthcare SystemNational Institutes of Health/National Heart, Lung, and Blood Institute (K23HL168233)NoneNoneNoneNoneNoneNoneAfshan HameedUniversity of California, Irvine Medical CenterNoneNoneNoneNoneNoneNoneNoneNadine A. KasparianCincinnati Children's Hospital, Medical Center, Heart Institute, Heart and Mind Wellbeing CenterNational 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.)NoneNoneNoneNoneNoneNoneElisabeth Breese MarshJohns Hopkins School of MedicineNoneNoneNoneNoneNoneNoneNoneRina MauricioUniversity of Texas SouthwesternNoneNoneNoneNoneNoneNoneNoneJenna SkowronskiUniversity of Pittsburgh Medical CenterNoneNoneNoneNoneNoneNoneNoneDiana WolfeAlbert Einstein College of MedicineNoneNoneNoneNoneNoneNoneNoneThis table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on 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 $5000 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 $5000 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.
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on 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 $5000 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 $5000 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
ReviewerEmploymentResearch grantOther research supportSpeakers' bureau/honorariaExpert witnessOwnership interestConsultant/advisory boardOtherLaPrincess C. BrewerMayo Clinic, Department of Cardiovascular MedicineNoneNoneNoneNoneNoneNoneNoneEmily LauMassachusetts General HospitalNoneNoneNoneNoneNoneNoneNoneJennifer LeweyUniversity of PennsylvaniaNoneNoneNoneNoneNoneNoneNoneShiv Darius TandonNorthwestern University Feinberg School of MedicineNational 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.)NoneNoneNoneNoneNoneNoneSammy ZakariaJohns Hopkins University School of MedicineNoneNoneNoneNoneNoneNoneNoneThis 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 $5000 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 $5000 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.
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 $5000 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 $5000 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.
