Mental health response to disasters/other critical incidents

Diseases

Overview

Introduction

Mental health response to disasters and other critical incidents has been proposed as a method of reducing short- and long-term problems that might follow a single, distinct life event or a public disturbance.[1] [2] Originally arising from concerns about soldiers and first responders, the mental health dimensions of disasters and other critical incidents are now considered a priority in disaster planning, response, and research.

Several groups have worked on consensus recommendations for the management of disasters and other critical incidents. A trauma group in the US has proposed a management strategy.[3] The European Network for Traumatic Stress (TENTS) conducted a three-round Delphi process, and other organizations have also developed guidelines from consensus.[4] [5] [6] [7] From Chile, a similar model has been proposed based on a literature review.[8] While the scientific evidence base for responding to the immediate- and, to a lesser degree, long-term mental health aftermath of trauma and disaster is still emerging, the content in this topic reflects the best practices in this area based on available expert consensus and experience.

Definitions

Critical incidents range from small-scale events, such as failed cardiac resuscitation, to very large-scale events such as disasters. Such serious threats are stressful and may lead to a wide array of immediate and lingering symptoms and illnesses, at both individual and organizational levels. Critical incidents are defined differently in different contexts. What is common across the definitions is that the event threatens the continuity of the individual or the collective existence of the community.[9]

It is worth situating critical incidents along a spectrum. Stress may be thought of as disturbance in an individual's equilibrium, and can be physiological, psychological, interpersonal, or environmental in origin; it is anything that disrupts a person's sense of balance but for which they have the coping mechanisms to recover.

A trauma involves exposure to actual or threatened death, serious injury, or sexual violence. Trauma occurs via one or more of the following: directly experiencing the traumatic event; directly witnessing someone else experiencing the event; learning that the event occurred to a close family member or close friend; or experiencing repeated or extreme exposure to aversive details of the event.[10]

Finally, a disaster is a trauma that overwhelms a community. For simplicity, only disasters - the largest and most complex of critical incidents - will be described hereafter; however, the principles should apply to all such incidents.[11]

Preparing for disaster

Healthcare providers are part of the official first-responder group, and should be involved in community- and hospital-based disaster preparation training on a regular basis. One useful personal continuing education activity is for healthcare providers to read the Psychological First Aid Field Operations Guide.[12] [13] It provides a helpful overview of immediate response to disaster. Another helpful resource is the World Health Organization (WHO) guide to psychological first aid.[14]

Disasters are chaotic situations, in which the rules are suddenly changed. Roads may be destroyed, communication systems dysfunctional, and horrific loss of life incurred, all of which make the usual functioning nearly impossible. Although we cannot know for certain the ways in which the disaster will change the setting, research on disasters has taught us the types of challenges that we are likely to face and the ways in which our reactions to those problems may not lead to a solution.[15] For example, after a disaster, people take themselves or others to the hospital, without asking the officials who are in charge. This means that systems of triage have much less chance to work as patients collect en masse at the nearest or best facility. Training can help in this situation, but must plan for the spontaneous reactions of many people.

An organized response to a disaster involves the assessment of the stricken community's past experience(s) with disasters, a needs assessment about its current situation, and integration of that information into pre-existing protocols. Ideally, the clinicians who are then deployed already have pre-event training in those protocols or will be able to undergo efficient, just-in-time training around them.

The mental health impact of disasters

The mental health impact of disasters can best be understood in temporal relation to the event.[11] The acute period can be understood as occurring from hours to days to the early weeks afterwards, while the post-acute period occurs from weeks to months to years afterwards. It is difficult to precisely determine the temporal border between these two periods, but conceptually the acute period can be thought of as when the event(s) are still underway, while the post-acute period begins once the acute situation calms or normalizes.

During the acute period, symptomatic reactions, rather than psychiatric disorders, are the rule. Although recurrence of pre-existing disorders is possible during the acute period, it is not otherwise a time when diagnosis is appropriate. Acute reactions can involve distress responses (changes in how people feel); cognitive responses (changes in how people think); and behavioral responses (changes in how people behave).[16] Many such responses are normative and possibly adaptive. However, they are more likely to require clinical attention if they endure or especially if they beget dysfunction or undue distress. Although most evidence suggests that suicide rates are elevated primarily in areas with repeated exposures to disaster, any suicidality, however uncommon, warrants urgent clinical concern.[17]

If initial symptomatic responses persist, they may coalesce into new psychiatric disorders over time. During the post-acute period, psychiatric diagnoses become the focus of attention, as weeks or months later, even initially adaptive psychological responses surely will have outlasted their utility. The most common post-acute disaster diagnoses of concern are post-traumatic stress disorder, major depression, and alcohol use disorders, although other substance use disorders and grief reactions may also be common.[18] [19] Among these, alcohol use disorders are the most likely to reflect recurrence rather than new onset problems.[20]

Outreach and screening

In the post-disaster setting, especially acutely, with so many recovery-related practical issues facing survivors as they and their communities often literally try to rebuild their lives, mental health issues run the risk of becoming even less prioritized than usual even as they become more pervasive. Outreach and screening, especially in the acute period, are therefore essential to helping connect survivors with services.[19] [21] [22]

Outreach requires movement of mental health services into non-mental health settings, especially co-locating them among the array of post-disaster services being offered to a community in what are often called family assistance centers.[18] Other elements of outreach include publicity campaigns, reaching out to individuals with caseworkers or crisis counselors, partnering with communities or agencies, and identifying the target population(s) for these efforts.[23]

Active screening for psychiatric diagnoses in the post-acute phase in particular is essential because mental health sequelae of mass trauma are often not as evident as the resulting physical injuries.[19] Active efforts at screening and diagnosis in settings such as family assistance centers for conditions such as post-traumatic stress disorder (PTSD) and major depression are therefore essential. Even outside the context of a major disaster, the American College of Surgeons recommend that trauma centers carry out brief screening for all patients at risk of psychological distress (including depression and PTSD) following physical trauma. Risk factors noted include prior psychiatric history, prior trauma exposure, the characteristics of the injury, and the patient's post-injury reaction.[24]

Screening instruments can be used to efficiently trigger a clinical evaluation by a mental health or health professional. Assuming health professionals will be in greater supply on-site or in proximity, they can be used for initial evaluation of "screened-in" individuals and refer to mental health professionals for more challenging cases much as would be the case in usual primary care settings. For a review of the many validated screening instruments available, see North and Pfefferbaum, 2013.[19]

One excellent model for screening that has been proposed for traumatic injury survivors has just as much applicability to disaster survivors and involves the following:

Initial screening in the immediate days after the trauma/disaster
Follow-up phone screening at approximately 4 weeks for those survivors initially deemed at risk
Scheduling in-person treatment appointments for at-risk survivors who are found to be highly symptomatic.[25]

Citations

Key Articles

Sever MS, Vanholder R; RDRTF of ISN Work Group on Recommendations for the Management of Crush Victims in Mass Disasters. Recommendation for the management of crush victims in mass disasters. Nephrol Dial Transplant. 2012;27(suppl 1):i1-i67.[Abstract][Full Text]
World Health Organization. Psychological first aid: guide for fieldworkers. Geneva: WHO; 2011.[Full Text]
Gillies D, Maiocchi L, Bhandari AP, et al. Psychological therapies for children and adolescents exposed to trauma. Cochrane Database Syst Rev. 2016;10:CD012371.[Abstract][Full Text]
American Psychological Association. Clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD). Feb 2017 [internet publication].[Full Text]
National Institute for Health and Care Excellence. Post-traumatic stress disorder. Dec 2018 [internet publication].[Full Text]

Other Online Resources

The National Child Traumatic Stress Network
PTSD: National Center for PTSD
National Voluntary Organizations Active in Disaster
Medical Reserve Corps

Referenced Articles

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