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Improvements in post-disaster mental health care identified
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Effective community responses to disasters should include certain crucial steps — particularly the identification of psychiatric illness, triage and the provision of mental health interventions for those affected by catastrophe — according to the results of a recent review.
"Unlike physical injuries, adverse mental health outcomes of disasters may not be apparent, and therefore a systematic approach to case identification and triage to appropriate interventions is required," researchers wrote.
Carol S. North, MD, MPE, of the VA North Texas Health Care System and the University of Texas Southwestern Medical Center, and Betty Pfefferbaum, MD, JD, of the University of Oklahoma Health Sciences Center, reviewed more than 200 articles on mental health interventions and services related to community disasters. They found that 11% to 38% of distressed individuals involved in disasters who presented to shelters and family assistance centers had stress-related and adjustment disorders. Bereavement, major depression and substance use disorders were also present in many individuals.
Results also indicated that up to 40% of distressed individuals had pre-existing mental illness, and those who had more intense reactions to disasters were more likely to accept a referral to mental health services compared with individuals who were less affected.
According to North and Pfefferbaum, there has been no operational framework to guide mental health care in a disaster setting. A majority of the studies included in their review recommended various interventions or strategies without suggesting that disaster responses begin with an assessment that includes psychiatric diagnosis. The studies also typically excluded plans for individuals with pre-existing mental illness. Directing individuals affected by disasters to the appropriate mental health services can be cost-effective, as well, they said.
North and Pfefferbaum added that there is a limited evidence base for mental health interventions after a disaster, which are difficult to investigate in the midst of catastrophes.
"Evidence-based treatments are available for patients with active psychiatric disorders, but psychosocial interventions such as psychological first aid, psychological debriefing, crisis counseling, and psychoeducation for individuals with distress have not been sufficiently evaluated to establish their benefit or harm in disaster settings," the researchers wrote.
Disclosure: See the study for a full list of financial disclosures.
Perspective
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Elspeth Cameron Ritchie, MD, MPH
Carol North and Betty Pfefferbaum are well respected in the field. They've done a thorough review of the literature related to mental health services, public health services and emergency services. The article lays out the issues in a systematic way. First, mental health outcomes in disasters are not always apparent, and they're not always immediate. This is important because, often, teams of counselors are sent in right away to treat those affected by a shooting or a disaster when they really should be going in with the idea of doing an assessment, case identification, triage and providing interventions for the long haul.
Initially, the authors emphasize that rarely will someone with no previous mental health conditions experience full-blown psychiatric symptoms as a result of a disaster, but there may be exacerbations of pre-existing problems — either severe mental illness or psychological distress. Another important point in the article is the need for being able to do evaluations at shelters and family assistance centers and other non-traditional mental health clinics. Too often, mental health professionals sit in their offices and expect people to come to them, and they won't. Finally, we still don't know the best approach to disaster relief. There are things that we are currently doing, such as psychological first aid, which people are happy with and it appears not to be harmful, but we have little evidence that it works. What we do know is that psychological debriefings seem to be contraindicated. I've often thought of this field as the aircraft carrier turning around. Prior to 9/11, the arguments focused on psychological debriefings and whether those caused more harm than good. We've moved beyond debriefings and onto psychological first aid, but there's still a ways to go.
I agree with the authors that, in most cases, the severely mentally ill are left out of the discussion about disaster response. One of the aspects of disasters that I emphasize in the course that we offer to our responders in Washington, D.C., is that, in most cases, there be power loss, which causes a disruption of medication in pharmacies. Those with chronic mental illness will go off their meds, and they often become disruptive. In a disaster, the police often does not have a tolerance for disruptive behavior, and we saw that during Hurricane Katrina in New Orleans, where people lost their lives when they were disruptive in the Superdome and other shelters and on the street.
In terms of doing an assessment, I would recommend PsySTART, which is a tool that is increasingly being used by the Red Cross and other organizations.
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