Understandably many obstetricians, midwives, and other health providers who treat pregnant women are facing their patients' growing anxiety about the Zika virus. At Seleni, where we provide mental health counseling to pregnant women, we have already seen a spike in our intakes and concern among our existing patients related to potential Zika exposure. These concerns and anxieties will only grow as the virus continues to spread to other countries and within the United States.
Any global health crisis with the potential to impact a developing baby is not only a stressor for pregnant women, but also a risk factor for developing a perinatal mood or anxiety disorder (PMAD). As a prenatal care provider, you have a unique opportunity to help women deal with these fears and concerns and refer them to mental health treatment and support as needed.
How a patient may respond to potential Zika exposure
Even under the best circumstances, pregnancy is often a time when a woman's anxieties emerge because of her desire to keep her baby safe as well as individual responses to the dramatic hormonal changes of pregnancy. With the Zika outbreak, there is so much we don't know about the virus, and the information available changes from day to day. Microcephaly is also a devastating possible outcome to a pregnancy. Considering all these additional factors, you can expect to see many pregnant women in your practice with a high level of concern about Zika – whether or not they have been exposed.
The distress a pregnant woman may feel in response to Zika will be determined by the way she responds to distress in general. Depression, general anxiety or panic disorder, OCD, or PTSD are all disorders that encompass PMADs, and women who have a history or a risk of developing any of these conditions now have an additional potent stressor and source of anxiety that might contribute to developing a PMAD.
Tools to help women and families
1. Acknowledge their concerns. It's scary to learn about a global health threat and have so little information about its impact and the way it is transmitted. Acknowledging that this is a real concern will go a long way to help women and their families stay calm, but at the same time does not provide false assurances. Empty assurances, such as, "Everything will be ok" will ring hollow to a woman who has a legitimate exposure concern and will minimize real distress any patients may be experiencing. This, in turn, makes it less likely they will get the support they need to manage it. Of course, reassurances based on data and information about a patient's actual risk can be helpful.
Also acknowledge that the unknown magnitude of this crisis is a valid concern. Emphasize that it is not one to be ignored and not one with easy answers, but that you will work together to find the most reliable information to help her manage the understandable distress.
2. Be empathic and calm. In the field of mental health, we often begin difficult discussions by showing our concern and willingness to engage in the conversation. Good starting points include something along the lines of, "Tell me more about what is distressing you," or "It's clear this is a distressing time for you. Can you tell me more?" You could also ask a patient what other thoughts or feelings she has been experiencing besides anxiety. All these entry points will help a patient feel more comfortable about opening up and disclosing her true concerns.
3. Perform a risk assessment. Even if you believe that it is very unlikely your patient has been exposed to the Zika virus, it will help her to know you take her concerns seriously. Explain that doing a risk assessment will help her cope with the uncertainty, and the end result of the risk assessment should provide her reassurance. Staying calm during the risk assessment models behavior that can help your patient cultivate calm as you evaluate next steps together.
4. Have a direct conversation about fears and anxieties. As your patient's pregnancy care provider, you are probably the first medical professional to hear your patient's concerns. If a risk assessment shows that her risk of exposure to Zika is low, be prepared to have a conversation about managing fears and anxiety. If the assessment suggests a higher level of risk, be prepared to have the same conversation about managing fears and anxiety while also exploring next steps in her care.
Tools you can offer your patient to manage fears and anxieties
Here are some interventions we have used at Seleni:
1. Explain that intrusive thoughts are common. Intrusive thoughts (such as fears about the baby's well-being) are a normal part of pregnancy and the postpartum period, and very often they occur in perinatal mood and anxiety disorders. After discerning that the intrusive thoughts are distressing for your patient, one of the most effective interventions is to educate her about how common these thoughts are. Having this awareness is often a relief and the first step toward becoming more at ease and feeling like herself again.
2. Recommend a break from the news and Dr. Google. We find it helpful to remind women who struggle to manage anxiety and worry that they may want to limit their online research and exposure to news coverage because these activities often only heighten anxiety. This is especially true in the case of Zika when the information (and level of concern) changes so rapidly. Instead, suggest focusing on something a woman can really control. This can be as simple as planning an outing with friends, which can de-escalate worry and the feeling of helplessness.
3. Suggest scheduling a time to worry. It can be helpful for patients with anxiety to set aside a short period of time in the day to worry. Suggest scheduling this on a calendar, keeping the 'appointment,' and moving on to other life activities when the time is up.
4. Encourage her to engage in activities that keep her in the present moment. Exercising can be a good option if medically appropriate. Other good activities for staying in the here and now are those that require simultaneous attention (like reading music) and action (playing the piano), or following a recipe and cooking a meal. These activities can all interrupt and reduce the intensity of anxiety.
How to screen for a perinatal mood or anxiety disorder
Anxiety about Zika is one of many potential stressors and concerns that pregnant and postpartum women might experience. And we know that screening for a developing PMAD is useful to see if further steps might be indicated. The US Preventive Services Task Force just recommended that all pregnant and postpartum women be screened for depression.
The first instrument recommended by the American Academy of Pediatrics (AAP) is the Edinburgh Postnatal Depression Scale. This simple 10-question screen has been validated in English, translated into several languages, and is generally regarded as the gold standard for identifying an increased risk of postpartum depression.
It's important to note that several items on "the Edinburgh" allude to anxious symptomatology, but clinicians familiar with the range of perinatal mental health disorders recognize that the instrument does not identify risk for generalized anxiety, obsessive compulsive, panic, post-traumatic stress disorders, or postpartum psychosis, which are all associated with the perinatal period.
The second instrument recommended by the AAP is a two-question screen. This reliable, validated screening asks whether, over the last two weeks, the respondent has felt:
• down, depressed, or hopeless
• little interest or pleasure in doing things
The screen is considered positive if a woman endorses either item, and this means she is considered at risk for depression. The two-question screen can be easily administered orally or in writing, but it has also been proven to identify only an increased risk for depressive symptoms.
Providers using either instrument are encouraged to follow up by asking childbearing women whether anything concerns them about the way they are feeling or the thoughts they are thinking. If a woman answers yes to this clinical interview question – or has screened positively on either instrument – a referral to a mental health provider for comprehensive assessment is appropriate.
Remember that these screenings are not intended to be diagnostic. A positive screening indicates only an increased risk for diagnosis, so patients who screen positively should be referred to mental health providers for comprehensive assessment. At this time, a diagnosis can be made and an appropriate treatment plan developed if necessary.
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