4 minute read

First published March, 2019. Original post here.

One of the first things I noticed when starting out as a BHC in an obstetrics/gynecology clinic was that every template or model for integrated care focused on primary care as the setting for behavioral health integration. Although much of that information is adaptable to ob/gyn care, the value of a community of behavioral health professionals working in ob/gyn has become apparent to me. The goals of this community would be to share ideas and to develop effective targeted interventions for issues that are unique to women’s healthcare.  

Perinatal Mood Disorders: Intervention and Prevention

BHCs can play a role in identification and outreach to at-risk perinatal patients: deploying both brief interventions and skillful referrals with benefits to families, providers and payers. BHCs and medical providers frequently receive feedback from women indicating that they would have been unlikely to seek out care for a perinatal mood issue, even a severe one.  Patients tell us that they agreed to a warm handoff or behavioral health appointment out of trust for their ob/gyn provider, and because the care was quick, available onsite, and came with minimal barriers. As a result of earlier intervention, symptoms tend to resolve more quickly.

By sharing ideas and documenting results, we could increase the use of early intervention with potential for real impact with this population.

Miscarriage, pregnancy termination, stillbirth, neonatal death and infertility

Being in the right place at the right time is especially important in the many situations involving loss and grief in Ob/Gyn care.   There is a look of surprised relief in many patients’ eyes when I come in for a warm handoff after they have discussed or learned of adverse pregnancy findings or are in the throes of decision making with their medical provider.   BHCs provide space, time and expertise to process these experiences as they occur, in the initial period after a loss or while navigating the uncertainty of a high-risk pregnancy.

We are able to provide a gentle touchpoint in the direction of self-care during the immediate crisis as well as monitoring for common complications of this type of grief such as insomnia, isolation, guilt, loss of self-efficacy, hypervigilance, suicidal ideation and ruminative self-doubt. Those with multiple losses or pre-existing mental health challenges may ultimately find a relationship with an ongoing mental health provider most beneficial but I rarely hear from a patient that they feel our time together was wasted.  

Exchanging information on this topic could offer us new ways to help our patients cope at this difficult time.

Perimenopause and menopause:

Symptoms of perimenopause and menopause such as weight gain, low libido, insomnia, vasomotor symptoms and depression may result in a referral to behavioral health. The factors contributing to these symptoms tend to be complex: many patients are in their most productive working years, are raising children or teenagers, caring for aging parents, adjusting to an empty nest, contemplating or experiencing divorce or recognizing that they are no longer willing to live within certain societal constraints that they had previously accepted.  

Some women use alcohol or marijuana to cope, and need support to decrease or cease use. Some are ready to dive into an ongoing therapeutic relationship and just need help connecting to that care. Others have ventured far enough from their comfort zone just meeting with me in the clinic but are open to ideas about how to improve their quality of life and functioning. Because many patients have a good amount of insight by this point in their lives, they readily soak in some of the “nuggets” offered in brief visits and are often eager to take next steps on their own or with a limited number of follow up visits.

By pooling our knowledge and experience in this area, we can provide additional resources for this group of patients.

Pain—menstrual, sexual, chronic pelvic and more

Supporting patients related to their experiences with pain is, of course, a mainstay of integrated behavioral health practices.  When working specifically with female reproductive organ and pelvic pain, there are some additional factors to consider:

There exists a long history of dismissing women’s pain or attributing it to women being excessively dramatic. At the point I meet them, most patients feel that their concerns are being taken seriously by their gynecologist, though it may have taken months or years to be referred there. By some estimates, the average time from initial complaint to a diagnosis of endometriosis is 8 years.  I try to keep this in the forefront of my mind as I assess for and provide education about the role of trauma, depression and lifestyle factors that can contribute to a worsening experience of pain. My hope is to not dismiss or diminish concerns but rather shine a light on the constellation of interventions that tend to improve symptoms.

Many women also struggle with shame and internalization of distressing issues such as painful sexual activity and severe pelvic pain, particularly if a diagnosis has not yet been given to explain these symptoms.   In these situations, patients may feel understandably overwhelmed by too much direct questioning and require an especially sensitive approach – i.e. we need to slow down sometimes! Behavioral health can play a key role of support between or in conjunction with medical provider visits to learn coping strategies, obtain support or connect to ongoing mental health care as helping women address some long-avoided topics.  

What other ideas do you have about supporting women experiencing these challenges?

How can we improve the care we provide?

Women discuss a wide variety of issues with their ob/gyn. Many of these are ideal for a warm handoff to a BHC in order to continue the conversation and to provide support and intervention. There will never be a one-size fits all approach to any issue we see in behavioral health. However, for issues like diabetes, hypertension, tobacco use and even depression, we recognize the impact on well-being, can measure severity and evaluate progress, and have a toolbox of evidence-based interventions to use to help.  

The benefit of a community of practice focused on women’s health would be to push forward an evidence-based approach to the areas discussed above.

Join in to talk about needs you see or anticipate in your setting. All are welcome, even those just interested in learning more!

Additional note:  I was thrilled to read the February 2019 US Preventive Services Task Force (USPSTF) findings regarding prevention of perinatal depression.  The USPSTF concludes with moderate certainty that counseling interventions toprevent perinatal depression have a moderate net benefit for persons at increased risk. They also highlight the potentially promising role of “embedded behavioral health specialists” in improving health system delivery of these interventions.  To read more: (https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/perinatal-depression-preventive-interventions )