Managing the psychiatric morbidity of disasters

Predicting the morbidity from disasters requires clear conceptual frameworks about the different categories of victims and also the manner in which the consequences emerge over the passage of time. Disasters by their nature are events that create confusion and challenge the ordinary structures within a society to manage the basic needs of that social group. A clear conceptual map is of considerable help in minimising the sense of chaos and restoring the provision of needs. There is now a sufficient body of data about the psychological impacts of disasters to begin to think about these events from a broad conceptual framework. In essence, these are events where an environmental stressor can be conceived of in a similar way to a physical environmental toxin that creates a risk in those with differing degrees of exposure. The management response can be informed by using public health models for minimising the consequences of exposure and ensuring broad based approaches are applied.

Unfortunately, however, the essence of disasters is their unpredictable nature. One of the problems with disaster plans is that they are based upon the experience from the previous catastrophe. It is always critical that the management's strategies are highly flexible and based upon a constant reappraisal of the needs of the victims. For this reason, it is important that the survivors are not categorised in an excessively rigid way.

For example, individuals that are typically associated with rescue and recovery can at times themselves, also be primary victims of the event if they arrive at the scene as the catastrophe unfolds. The death of a significant number of fire fighters in the World Trade Centre collapse on September 11, 2001 is indicative of this issue. Furthermore, with the increasing frequency of travel, many disasters involve victims from a very wide geographical spread. This is perhaps best exemplified in circumstances of an aircraft accident. The establishment of a disaster management service within the local community will address the needs of the rescue personnel and any individuals affected who were resident at the site of the crash. However, structures also need to be able to establish outreach to the communities from where the victims came. This is again a challenge to many disaster plans, which are often organised at a regional rather than national level.

The interest in disaster affected populations is intense in the first days and weeks that follow these events. Often, communities are overwhelmed by offers of help and assistance. One of the challenges in managing the mental health response to a disaster is to create a momentum in these early weeks that leads to the establishment of programs that function over a period of years in the aftermath of the event. Although the awareness of the importance of traumatic stress as an aetiological factor in mental illness has increased significantly in recent times, few public mental health services are well equipped with specialist skills in this domain. While disaster plans may be in place, it is critical to check the level of expertise within the organisations that are designated to provide these interventions. Disasters can provide an opportunity to upgrade the skills and re-direct the interests of mental health services so they are then better able to deal with the victims of multiple traumatic stressors that occur day to day within communities. Significant rates of traumatic stress as a consequence of violent crime and motor vehicle accidents tend to go unnoticed because of the isolation of the victims. People who have survived these events do not attract the same public concern or empathy as the victims of a disaster. In the aftermath of an event, maintaining a focus on individual victims is a way of ensuring that there is an embedded body of skill within a community who can then respond if some larger scale event occurs. The workers within community mental health systems often welcome such an initiative as it provides them the opportunity to work with a different range of clients than would normally be demanded.

As the popularity of the psychological care of disaster victims has risen, a new problem has emerged. There is the phenomenon of convergence where many mental health professionals eager to assist can tax the resources of the organisation trying to manage the acute response. It is critical that systems be put in place to limit the contact with victims during this phase and also to have some check on the credentials and skills of people who come forward to provide assistance. It is important that a list of all the individuals who are contacted by each service provider are stored centrally so that systematic follow up and auditing of these interventions can occur.

There is also a danger in that bringing in experts in the management of the acute phase of the event, if not carefully integrated with existing services, can disrupt the natural community networks that would be facilitated at the time of such events. The general practitioners and primary health networks play a central role in dealing with the mental health effects of most disasters. The majority of the population prefer to seek the assistance of individuals with whom they are already familiar and can trust. An essential element, therefore, of any mental health plan is to upgrade the skills of these primary health care workers and general practitioners in the immediate aftermath of the disaster. The demands that they will have to meet will be in the months and years that follow. Many victims are willing to tolerate their distress and symptoms in the first weeks and even months after the event. It is only when time fails to heal that there are increasing rates of presentation to health services. Then many people present with physical symptoms rather than simple psychological distress. It is important that this time lag is capitalised upon so that training can be put in place to upgrade the skills of the providers during that period of time.

Whilst the debriefing movement has done much to heighten an awareness of the psychological impact of these events, it is important to recognise the limitations of this approach. The early promise of its effectiveness in the prevention of post-traumatic stress disorder (PTSD) has not been realised (1,2). Providing early services, therefore, does not minimise the need for planning for systems of care for victims in the medium to longer term. The nature of the post disaster environment can be a critical issue in determining the levels of morbidity. Therefore, one central role of individuals in planning post disaster interventions is to assess these risk factors and to define populations who are likely to be in particular need of assistance.

Research plays a critical role in the aftermath of these events, both because of the specific and general lessons learned. Many emerging understandings of PTSD have arisen from carefully planned epidemiological research in these settings. These findings also have direct benefits to the populations because they do provide a method for monitoring and assessing the outcomes. Disasters involve the exposure of populations to stresses that are not infrequent within individual communities. The collective consequences are very useful for highlighting the increasing evidence about the detrimental impact of these events on the mental health and well being of the exposed communities and individuals.