Disaster Psychiatry: What Psychiatrists Need to Know
Disaster Psychiatry: What Psychiatrists Need to Know
Disasters and public health emergencies, such as epidemics, can lead to significant community-wide disruptions. Appreciation of the psychiatric consequences of disasters and public health emergencies has increased significantly in the past decade. The most commonly reported symptoms after a disaster are sleeplessness; anxiety; depression; and constant, overwhelming bereavement.1Posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and substance abuse are more prevalent in communities in which traumatic events have occurred.2-4 The Institute of Medicine Committee on Responding to the Psychological Consequences of Terrorism noted the importance of focusing not only on disaster pathologies but also on disaster stress behaviors.
Psychiatric disorders do not affect all individuals who have experienced a disaster; however, they are at increased risk for distress behaviors that have equally significant and long-term consequences. Distress behaviors include increased smoking, chronic irritability, and even overwork.5,6 Disasters and public health emergencies engender a wide range of public health concerns. Psychiatrists have a key role in disaster response: competency in addressing the psychiatric needs in post-disaster communities is critical. A broad public health approach in caring for the victims and the overall community after a disaster is essential.
Disasters place additional stress on preexisting social frictions along cultural, economic, or political lines. Feelings of marginalization by individuals and communities may be exacerbated in the aftermath of the event. Such stresses can contribute significantly to individual and population responses after disasters, including concerns of backlash toward specific cultural groups.
Professionals may also feel they are being marginalized. Such was the case with some health care workers during the severe acute respiratory syndrome (SARS) outbreak: some community members worried that they would contract the disease because their clinician had been exposed to patients with SARS.7
Several factors can influence psychiatric risks after disasters. The nature of the disaster can contribute at both individual and community levels. Small-scale or localized disasters (eg, aviation disaster, mass shooting) may be time-limited; other disasters (such the aftermath of a hurricane, an epidemic, or ongoing terrorism) may persist over a longer period.
The resulting number of deaths, severity of injuries, and property destruction, as well as the size of the affected geographic area, can influence how at-risk individuals and communities fare. In general, people seem to respond better to natural disasters than to man-made disasters.8 A history of psychiatric disorder or trauma potentially increases risks. Additional individual risk factors include sex and age, actual and perceived level of support, and coping skills. There are also community risk factors, such as trauma experience, disaster response experience, level of social support, and community leadership.
As disaster responders, psychiatrists can take leadership roles on multidisciplinary teams to help organize and provide post-disaster psychiatric care.8 They can provide direct assessment and needed interventions. As such, every psychia-trist has a vested interest in acquir-ing basic competency in disaster psychiatry.
To better understand how psychiatric care can be integrated into the overall disaster response process, it is important to conceptualize the 3 phases of a disaster:
• Pre-event phase: the focus is on disaster education, mitigation, and preparedness
• Acute response phase: the acute or actual disaster response; this phase can last hours to weeks, depending on the nature of the event
• Post-event phase: disaster recovery; this phase can last for months or years, again depending on the severity of the event
►The prevalence of major depressive disorder, posttraumatic stress disorder, and substance abuse is increased in communities that have experienced traumatic events.
► For many patients, stress may not be directly related to disaster itself but rather to post-disaster chaos.
►Licensure and credentialing represent an important medicolegal challenge for psychiatrists who do disaster work. Know the requirements of the state where you will be doing the volunteer work. The American Psychiatric Association can provide information regarding licensure in disasters.
►Self-deployment to a disaster can add to chaos, prevent adequate distribution of health resources, and expose you to danger (eg, aftershocks from earthquakes, exposure to chemical/biological/radiological events).
This phase involves learning more about the mental health effects of disasters and some potential interventions. It is important to learn about risk factors and factors that can help mitigate disaster stress. It is crucial to know who is part of the disaster response hierarchy in the community, including agencies that respond to disasters and their responsibilities. These agencies include first responders, such as police and fire departments and emergency medical services, as well local and state health departments and emergency management agencies.
Psychiatrists who work in hospitals or institutional settings need to know what disaster plans are in place as well as how they can participate in the planning process. Individual psychiatrists can identify agencies that they can volunteer for in the event of a disaster. Finally, it is important that psychiatrists discuss a potential crisis plan with their patients. The plan should include information on how the patient can manage his or her mental health and how to obtain medication and treatment after a disaster.
People experience a spectrum of reactions as a result of traumas (Table 1). Disaster stress reactions encompass physical, emotional, cognitive, behavioral, and spiritual areas (Table 2). The psychiatrists can provide triage and interventions for those who are in distress. Helping affected individuals obtain basic needs, including food and shelter, is an important early intervention.