Boston Marathon: An opportunity in mental health care

The devastation caused by the deadly bombings at the Boston Marathon affected many lives, but the tragedy may present an opportunity for clinicians to deliver more effective mental health care, according to some experts.

Sandro Galea, MD, chair of the department of epidemiology at the Columbia University Mailman School of Public Health, said the provision of psychosocial support for victims directly affected by the bombings can help mitigate subsequent mental health problems.

Sandro Galea

“In the long term, treatments such as cognitive-behavioral therapies or pharmacotherapies may be needed for those who go on to have longer-term mental health problems,” Galea told Psychiatric Annals.

Many who were exposed to the violent attacks in Boston may experience intense and transitory symptoms of distress, including nightmares or insomnia, according to Anand Pandya, MD, a psychiatrist at Cedars-Sinai Medical Center.

“However, most people are resilient after disasters and terrorism, so clinicians should not jump to giving diagnostic labels,” he said.

Although victims who were most directly affected or were injured are at the highest risk for mental health problems — and certain pre-existing conditions may compound that risk — most involved in the tragedy will not develop PTSD or other anxiety-spectrum disorders, according to Sander Koyfman, MD, president of the nonprofit group Disaster Psychiatry Outreach.

Sander Koyfman

“At all costs, avoid over-pathologizing,” Koyfman said. “Most reactions are transient and will not lead to long-term problems. Be on a lookout for any risks of self-harm or increase in high-risk behaviors and educate yourself if basic trauma response skills were not a part of your ‘tool box’ up to now. Better yet, find an organization or a group that can allow you to meaningfully participate in the response — this can range from attending vigils to fundraising to providing direct care — whatever suits your situation best.”

Koyfman, who also is a medical director of adult inpatient psychiatry at Kings County Hospital in Brooklyn, N.Y., cited the clinical guidelines on the US Department of Veterans Affairs website as an important resource.

Into the spotlight

Clinicians may feel the urge to assist victims in the immediate aftermath of a tragedy like the one in Boston, but their expertise may not be needed right away, or even not at all. Mental health professionals who participate in disaster relief may not be doing so for the right reasons, either, according to Craig L. Katz, MD, and Asher B. Simon, MD, of the Icahn School of Medicine at Mount Sinai.

Craig L. Katz

“As psychiatrists, we often practice in the shadows, quite solitary in our practice, and not feeling routinely ‘needed’ by the public in substantive ways,” Katz and Simon recently wrote in an article published online for Psychiatric Annals. “Disasters change this, and there is something quite energizing and rejuvenating to be foisted into the popular press in a positive and hopeful light, in contrast to the well-worn spectre of stigmatization.”

Decamping from their quiet practices to the national spotlight, clinicians are liable to overemphasize the mental health impact of disasters, especially when the basic provisions of safety, medical care, food, shelter, and family and social support are most needed to alleviate much of the victims’ immediate distress. Katz and Simon said clinicians must be aware of what informs their decision-making to facilitate the appropriate treatment.

Asher B. Simon

They added that the psychological sequelae of traumatic events are often forgotten during times of peace. Instead of forcing a victimized community to be more mental health-oriented in the immediate aftermath of a disaster or terrorist attack, the public should be mentally healthier to begin with, which can lower risks for psychological fallout.

“At the least, disasters provide opportunities to look at mental health systems and strengthen them and their communities for the future,” they wrote.

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Although there is no surefire way to "inoculate" the public against the mental health impact of deadly violence, Koyfman believes that the efforts to prepare for tragedies like the one in Boston have already been well under way.

“More and more professionals such as emergency room physicians, social workers and psychiatrists in the course of their training are learning about the basics of trauma response,” he said. “The familiarity with the themes has grown significantly — but as for 'inoculation' — for general public, with relatively low chances of any given individual's exposure to a large-scale trauma — education of the first responders and 'just in time' training and appropriate professional interventions may still be the more practical way to prepare.”

According to disaster psychiatry expert and retired Army Col. Elspeth Cameron Ritchie, MD, MPH, mental health professionals have become much more sophisticated in their treatment of disaster victims. However, clinicians are still in a position to do more harm than good.

Elspeth Cameron Ritchie

"First of all, mental health professionals should not be rushing to the scene of a disaster, at least not to provide mental health," she said. "If they're there to perform immediate, life-saving medical interventions, then they certainly can be useful ... but, in general, mental health needs to be prepared before an accident."

As chief clinical officer of the Department of Mental Health for the District of Columbia, Ritchie is in charge of disaster mental health in that city. She said there has been a large emphasis on preparation, and after an incident like the one in Boston, mental health professionals in Washington, D.C., are ready to perform an assessment of the victims and then offer an intervention if one is needed.

"That's been a major shift over the last 15 years," she said. "We used to just run in with the one intervention — the Critical Incident Stress Debriefing. It was, 'Let's all sit in a group and talk about what happened' 3 hours after the event. People just weren't ready for it. ... And what we've realized now is that could do more harm than good. It can exacerbate distress. In addition, distress doesn't emerge immediately. Maybe someone is cool, calm and collected at the time, but there may be lingering aftereffects for months or years. Having said that, the majority of people do OK. Unfortunately, these days, terrorism and disasters are a part of life."

Richie said perhaps the best psychological safeguard against acts of terrorism or disasters is for the public to feel physically prepared for these events.

"So, in other words, if something happened, and you have whatever you need to get home safely and make sure you're getting your kids home from school safely ... if you have a good response plan that you develop — that's going to make a difference," she said.

For more information:

O’Donnell ML. Clin Psychol Rev. 2008;387-406.

US Department of Veterans Affairs. Psychological first aid: field operations guide. Available at: http://www.ptsd.va.gov/professional/manuals/psych-first-aid.asp