Mental health intervention and high-risk groups in disasters.
Authors: Carol S Fullerton, Robert J Ursano
Journal: World Psychiatry (2002)

Raquel Cohen's paper provides all psychiatrists and mental health care providers with the opportunity to update their disaster psychiatry skills. Since September 11, 2001 and the World Trade Center terrorist attack, the import of the article by Cohen is all the more. Disasters, human made and natural, as well as war and terrorism, which are of course another type of human made disaster, affect the lives of millions throughout the world. Natural and human made disasters disproportionately impact the most vulnerable of our populations, who are often housed and work in vulnerable areas near rivers, in earthquake prone areas and near factories and industrial plants. Following a disaster, appropriate mental health interventions may be forgotten or prioritized last due in the rush to respond. Support services and restoration of safety and physical health needs are always the first psychiatric interventions for the direct victims of a disaster. These are the elements of initiating the recovery and providing hope for the future (1).

The mental health needs after a disaster vary both by the impact and exposure and by preexisting vulnerabilities (2). There are those who have had no previous mental health problems and now suffer from post-traumatic stress disorder (PTSD). Approximately 34% of people exposed to the Oklahoma City bombing developed PTSD 6 months after the disaster (3); of them, nearly 44% had never had any prior psychiatric diagnosis. On the other hand, there are those who will experience a reactivation of a previous episode of psychiatric illness such as PTSD, depression or substance abuse. In addition, those who may have been able to manage before a disaster, using resources from the community to sustain themselves by getting to work on a transit system and having assistance with family needs, may now find that their support is less and not enough to maintain them in the community. In largescale disasters, the loss of one's medications and even the place where they were obtained can lead to both immediate and long-term increase in psychiatric illness. Finally, the mental health needs of the wider population who now fear either a second event or a new previous unsought-of terrorist attack (4), or still rising river or threatening tornado or toxic spill must be considered. Anticipation of exposure to a trauma can have a powerful effect on behavior, cognition and feelings and in itself can aid in predicting future psychiatric needs. The media can be and will, even if not planned, be part of the public education plan for recovery, directing expectations and informing on the process.

The needs of rescue and disaster workers as well as their spouses and significant others (5) is an important part of all disaster planning. These dedicated first responders work with survivors and victims, recover the dead and may suffer the loss of their colleagues in their often dangerous work. Identification with the dead ('It could have been me') may increase risk for PTSD in disaster workers (6). Planning for the care of rescue and disaster workers is best done prior to a disaster.

While spouses of those who died are often considered for mental health intervention, less often are provisions for care made for the parents of an adult victim who suffer the loss of their life's plan with the loss of their adult child.

Working with primary health care providers is an important part of reaching those who are injured. This group has high rates of psychiatric illness and requires a proactive psychiatric evaluation and assessment plan rather than relying on referral for care. In addition, the opportunity to educate primary care providers in recognition of bereavement, depression, PTSD and substance abuse can assist in the early identification for treatment and intervention.

Psychiatric care, including crisis counseling, psychotherapy, medication and education of health care providers and community leaders, requires preplanning the development of networks of concerned people to assure the needs of our patients and communities are met in times of disaster.