As the Zika virus spreads across 31 countries in the Americas, bringing with it the threat of microcephaly seen in Brazil, local and international public health experts are scrambling to assess the extent of the threat. Systems for epidemiologic surveillance are emerging, as are guidelines for pregnant women and those of childbearing age.
Amid all of this is the World Health Organization’s recently released guidelines, “Psychosocial Support for Pregnant Women and for Families With Microcephaly and Other Neurological Complications in the Context of Zika Virus” (http://who.int/csr/resources/publications/zika/psychosocial-support/en). These guidelines, an adaptation of previous interventions used in disasters, are a helpful resource for physicians.
The guidelines emphasize eight areas: having accurate information, what information is conveyed, how that information is conveyed, understanding common distress reactions, providing basic support, strengthening social support, teaching stress reduction, and educating mothers about parenting children with microcephaly. Readers familiar with psychological first aid (PFA), used in disaster response to provide basic psychological support, will recognize these elements as distillations of PFA specifically for Zika.
PFA focuses on addressing peoples’ basic physiologic, safety, and social needs as a means of addressing their overall psychological needs. It has been promulgated as a best practice by the National Institute of Mental Health since the Sept. 11, 2001, terrorist attacks.
Another useful aspect of the guidelines is that they are aimed at health professionals in general, rather than mental health professionals in particular. This approach makes sense, because women concerned about potential infection with Zika, of course, are not going to go to a mental health professional to address their anxiety but to an internist, family physician, ob.gyn., or possibly a pediatrician. They are understandably focused on the distressing problem rather than on the distress itself.
Health care professionals now on the frontlines of the Zika public health response may naturally be following many of the principles in the psychosocial guidelines. Nevertheless, they probably would benefit from reviewing them in order to lend some more structure to the psychosocial soundness of their practice. In addition, becoming aware of the guidelines might help those health professionals deal with their own risk for burnout.
In discussing common distress reactions, the guidelines note that severely distressed individuals should be referred for “specialized care,” which means a mental health professional when psychosocial care is discussed in low-resource settings around the world. The overwhelming majority of countries in the Americas where Zika transmission has been reported are low- and middle-income countries, according to the World Bank’s ranking system. As such, they are surely the places where governments are most likely to devote the least amount of their health care budgets to mental health services.
And, even in high-income countries among the list of Zika-affected countries, it is not clear from consulting the World Health Organization’s 2014 Mental Health Atlas that even those countries fund anything more than inpatient psychiatric care (for example, information from Barbados lists only inpatient psychiatric resources). My point? The ranks of mental health professionals in Zika-affected countries who might benefit from the WHO’s Zika guidelines probably are few. Those who are there probably are overwhelmed tending to the preexisting (mostly inpatient) psychiatric needs of their countries.
Fortunately, the WHO’s Mental Health Atlas shows Brazil to be an exception with a comparatively robust outpatient as well as inpatient public mental health system. This is fortuitous given that Brazil for the moment is the center of the surge in microcephaly. Hopefully, the Northeastern region of Brazil, where that surge is highest, has a proportionate share of Brazil’s mental health resources. For mental health professionals there and potentially elsewhere in Zika-affected countries, the guidelines for psychosocial support can prove to be an essential tool.
To the extent that mental health professionals can and should provide support to their Zika-affected communities, these guidelines will help them to “stand down” from a traditional psychiatric model of care to a more normalizing one, where diagnoses and treatment are not the focus of attention. This was certainly the case in the comparable setting of post-Ebola Liberia, where mental health clinicians trained by the Carter Center found PFA central to what they could offer their devastated communities and to gaining unprecedented acceptance from those communities (unpublished observations).
As of this writing, the Zika virus has not spared the continental United States. Florida has been hit the hardest, followed by Texas, according to data from the Centers for Disease Control and Prevention. Those of us looking to help patients deal with the possibility of coming in contact with the Zika virus should remember the WHO psychosocial guidelines. They can help health professionals integrate mental health into their practices, and help mental health professionals transfer their skills and knowledge to their communities.