Disaster mental health care: the experience of Turkey

The comprehensive review by Raquel Cohen puts forward a systematic approach to mental health services for disaster survivors. Mental health workers are nowadays increasingly aware of the necessity to be equipped with the abilities required in effective disaster work, since the world is becoming more insecure in terms of traumatic life events. People are struck with either man-made disasters, such as terrorist attacks affecting thousands of people, industrial accidents and war, or natural disasters, such as earthquakes, floods or tornadoes. In natural disasters, one can also clearly see that the impact of human-made errors, such as unsafe construction of buildings or lack of environmental policies, increases the likelihood of losses.

The literature on disaster psychiatry emphasizes the features of populations at risk, in order to support the affected populations according to their mental health priorities (1,2). The classification in Cohen's paper, indicating the post-disaster need differences, gives a shortcut for major differences of exposure to the effects of disaster. The 'primary survivors', who have experienced the maximum exposure to the effects of the disaster, are obviously the group that should have the highest priority for medical and mental health interventions. The other groups, with a descending order of exposure to the traumatic event, have their own unique needs for medical care, community aid and psychological support.

Disasters, having a global impact on a community, are different from other traumatic events such as an airplane crash, traffic accident or assault. They undermine the material and moral resources of the whole community, affecting the social structure, leaving the survivors under a greater risk for potential psychiatric morbidity (3). Mental health services should be planned in advance for the post-disaster period, since available resources can better be allocated before the disaster strikes the community.

August 17, 1999 was a date of collapse, grief and great personal and material loss for the population of the Marmara (North-Western) Region of Turkey. An earthquake (7.4 on the Richter scale) caused the death of 18,000 people according to official records, injured around 50,000 people and left thousands of people homeless. The epicenter was in the Marmara Region, which is the area in Turkey with the highest population density. It is estimated that 20 million people were exposed to one of the most devastating earthquakes of the 20th century. On the other hand, a remarkable support was provided by the international community by disaster aid, rescue efforts, financial resources, and medical and mental health services.

The 'post-disaster time frames' indicated by Cohen were experienced step by step in the 1999 earthquake. Psychiatrists, under the umbrella of the Turkish Medical Association and the Psychiatric Association of Turkey, the Turkish Psychologists Association, the Psychiatry Departments of major Universities, and the Bakirköy Research and Teaching Hospital for Psychiatry and Neurology, organized outreach services in the disaster area.

Training provided by experienced Turkish and foreign colleagues went hand in hand with outreach services that were organized in tent camps, gathering places of the survivors and medical and rescue facilities.

The experiences of this period suggested that conventional clinical approaches should be modified in a flexible manner, according to the circumstances and the setting, where there is limited space, time and other resources, such as inadequate helping personnel, medication, rest and physical health.

A number of different studies in the first six months of the disaster showed a high prevalence of post-traumatic stress disorder (PTSD), ranging from 22.7 to 76% (4,5).

This period was a time of confusion, exhaustion and grief, but also a time of solidarity, heroism and efforts by non-governmental organizations. If the survivors were not motivated for their daily activities, they were observed as resorting to excessive demandingness, regressive behavior, and withdrawal from basic activities, which sometimes caused conflict between them and the aid staff.

Adapazari is one of the cities deeply affected by the earthquake where mental health services were initially inadequate. The 'Psychological Support and Psychiatric Treatment Project for Psychological Problems Caused by the Earthquake in Adapazari' (ADEPSTEP) was started due to this inadequacy five months after the earthquake by a group of mental health professionals from two major psychiatric departments in Istanbul. The main objective of the project was to assess psychiatric morbidity and psychosocial problems in the traumatized population, and to provide treatment and follow-up for 12 months. The population that was assessed (n=350) was a low-income group, and had a high level of personal and material loss (39.4% had a close relative who was killed by the earthquake). 60.5% of these people received a diagnosis of PTSD. In the group with this diagnosis, 44.7% had a comorbid depressive disorder, 17% had one or more anxiety disorders, 4.3% had a comorbid somatoform disorder (5,6).

The ADEPSTEP experience has provided valuable information on the long-term post-disaster phase. People with low socioeconomic status are reluctant to utilize mental health services. Community mental health services and education should be provided in the pre-disaster period. Trained psychiatrists cannot always provide on-site services in the long-term phase; therefore, training programs for primary care physicians have been developed and implemented in different regions of Turkey (7,8).

These steps should remind the professionals and the society at large that disaster mental health care should be a continuous effort. The process should start from the pre-disaster period by being prepared for the disaster in all aspects, and proceed through the different phases of the post-disaster period until the rebuilding efforts of the community and the individual accomplish the restoration process.