Mental health response todisasters and other critical

incidentsThe right clinical information, right where it's needed

Last updated: May 22, 2017

Table of ContentsOverview 3

Introduction 3

Definitions 3

Preparing for disaster 3

Themental health impact of disasters 4

Outreach and screening 4

Management of acutemental health responses 5

Management of long-termmental health problems 6

Role of systemsmanagement 7

Next steps 7

Online resources 8

References 9

Disclaimer 13

Introduction

Themanagement of critical incident stress has been proposed as a method of reducing short- and long-term problems(especially, but not exclusively, mental illnesses) 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 andother critical incidents are now considered a priority in disaster planning, response, and research.

Several groupshaveworkedonconsensus recommendations for themanagementofdisasters andother critical incidents.A trauma group in the US has proposed amanagement strategy.[3] The European Network for Traumatic Stress (TENTS)conducted a three-round Delphi process, and other organisations 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 basefor responding to the immediate- and, to a lesser degree, long-termmental health aftermath of trauma and disaster isstill emerging, the content in this topic reflects the best practices in this area based on available expert consensus andexperience.

Definitions

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

It isworthsituatingcritical incidentsalongaspectrum.Stressmaybe thoughtof asdisturbance inan individual's equilibrium,and can be physiological, psychological, interpersonal, or environmental in origin; it is anything that disrupts a person’ssense of balance but for which they have the coping mechanisms to recover.

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

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

Preparing for disaster

Healthcareproviders arepartof theofficial first-respondergroup, andshouldbe involved incommunity- andhospital-baseddisaster preparation training on a regular basis. One useful personal continuing education activity is for healthcareproviders to read the Psychological First Aid Field Operations Guide.[12] [13] It provides a helpful overview of immediateresponse to disaster. Another helpful resource is the WHO guide to psychological first aid.[14]

Disasters are chaotic situations, in which the rules are suddenly changed. Roads may be destroyed, communicationsystemsdysfunctional, andhorrific lossof life incurred, all ofwhichmake theusual functioningnearly impossible. Althoughwe cannot know for certain the ways in which the disaster will change the setting, research on disasters has taught usthe types of challenges that we are likely to face and the ways in which our reactions to those problemsmay not lead toa solution.[15] For example, after a disaster, people take themselves or others to the hospital, without asking the officialswho are in charge. This means that systems of triage havemuch less chance to work as patients collect enmasse at thenearest or best facility. Training can help in this situation, but must plan for the spontaneous reactions of many people.

Anorganised response toadisaster involves theassessmentof the strickencommunity’s past experience(s)withdisasters,a needs assessment about its current situation, and integration of that information into pre-existing protocols. Ideally,the clinicianswhoare thendeployedalreadyhavepre-event training in thoseprotocols orwill be able toundergoefficient,just-in-time training around them.

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OVERVIEW

OverviewMental health response to disasters and other critical incidents

Themental health impact of disasters

Themental health impact of disasters can best be understood in temporal relation to the event.[11] The acute periodcan be understood as occurring from hours to days, to the early weeks afterwards, while the post-acute period occursfrom weeks to months to years afterwards. It is difficult to precisely determine the temporal border between these twoperiods, but conceptually theacuteperiodcanbe thoughtof aswhen theevent(s) are still underway,while thepost-acuteperiod begins once the acute situation calms or normalises.

During the acute period, symptomatic reactions, rather than psychiatric disorders, are the rule. Although recurrence ofpre-existing disorders is possible during the acute period, it is not otherwise a time when diagnosis is appropriate. Acutereactionscan involvedistress responses (changes inhowpeople feel); cognitive responses (changes inhowpeople think);andbehavioural responses (changes inhowpeoplebehave).[16]Manysuch responsesarenormativeandpossibly adaptive.However, they aremore likely to require clinical attention if they endure or especially if they beget dysfunction or unduedistress. Of course, any suicidality, however uncommon, warrants urgent clinical concern.

If initial symptomatic responsespersist, theymaycoalesce intonewpsychiatric disorders over time.During thepost-acuteperiod, psychiatric diagnosesbecomethe focusof attention, asweeksormonths later, even initially adaptivepsychologicalresponses surely will have outlasted their utility. The most common post-acute disaster diagnoses of concern arepost-traumatic stress disorder,major depression, and alcohol use disorders, although other substance use disorders andgrief reactionsmayalsobecommon.[17] [18] Among these, alcohol usedisorders are themost likely to reflect recurrencerather than new onset problems.[19]

Outreach and screening

In the best of times, mental health services tend to be under-used, a situation arising at least in part from the stigmawhich continues to envelop mental health problems. In the post-disaster setting, especially acutely, with so manyrecovery-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 prioritised than usual even as they becomemore pervasive.Outreach and screening, especially in the acute period, are therefore essential to helping connect survivors withservices.[18] [20] [21]

Outreach requires movement of mental health services into non-mental health settings, especially co-locating themamong the array of post-disaster services being offered to a community in what are often called family assistancecentres.[17] Other elements of outreach include publicity campaigns, reaching out to individuals with caseworkers orcrisis counsellors, partneringwith communities or agencies, and identifying the target population(s) for these efforts.[22]

Active screening for psychiatric diagnoses in the post-acute phase in particular is essential sincemental health sequelaeof mass trauma are often not as evident as the resulting physical injuries.[18] Active efforts at screening and diagnosisin settings such as family assistance centres for conditions such as PTSD andmajor depression are therefore essential.Screening instruments can be used to efficiently trigger a clinical evaluation by a mental health or health professional.Assuming the latter will be in greater supply than the former, whether on-site or in proximity, health professionals canbe used for initial evaluation of 'screened-in' individuals, referring to mental health professionals for more challengingcasesmuchaswouldbe thecase inusual primary care settings.(For a reviewof themany validated screening instrumentsavailable, see North and Pfefferbaum, 2013.[18])

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

1. Initial screening in the immediate days after the trauma/disaster

2. Follow-up phone screening at approximately 4 weeks for those survivors initially deemed at risk

3. Scheduling in-person treatment appointments for at-risk survivors who are found to be highly symptomatic.[23]

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OverviewMental health response to disasters and other critical incidentsOVERVIEW

Management of acutemental health responses

Healthcare providers constitute one of the collaborative services to which referrals will be made. They are likely to seepeople who have suffered injury or loss andwho are having severe reactions to what they experienced. In the immediateaftermath of the critical incident, healthcare providers need to establish a thorough baseline of physical and mentalhealth.[18] [24] [25]

In the acute aftermath of disasters, people need to affirm the continuity of life, and to join with others to repair injury toself, social networks, and physical systems.[24] [26] [27] [28] At the heart of the successful management of a criticalincident is ensuring that the incident does not destroy the person or the person's society. Leading trauma researchersin the US, aware that there was no proven technique for mental health interventions after disaster, convened ameetingto assess what strategies were supported by evidence.[3] This group identified five essential elements:

• A sense of safety

• Calming

• A sense of self- and community efficacy

• Connectedness

• Hope.

Collaboration was undertaken by twomajor research centres to translate these 5 domains into actions that providerscouldundertake in the aftermathof disaster. The5principles identified in the first phaseof theworkhavebeen translatedinto 8 core activities:

• Contact and engagement

• Safety and comfort

• Stabilisation

• Information gathering

• Practical assistance

• Connection with social supports

• Information on coping

• Linkage with collaborative services.

These activities translate into the practice of psychological first aid, the mental health equivalent of medical first aid.These activities capture the basic, largely non-technical, interventions necessary to address common psychologicalreactions to disaster and ideally prevent them from becoming psychiatric disorders.[12] [13] [14]

As symptoms often tend to abate with time, supportive management is generally advised in the initial phase, exceptwhen faced with life-threatening issues such as suicidality and homicidality, or recurrence of pre-existing psychiatricdisorders. Vulnerable patients, including children, older people, and those with disabilities, especially need the aid of asupportive environment, and the healthcare provider, as part of the collaborative system, can refer to the people in thesystemwho are responsible for food, shelter, and social connection. At times, experience suggests judicious short-termmedication management may help relieve the symptom burden of some survivors, especially those with insomnia orsignificant anxiety, although the evidence base for this is still very limited.[17] [18] [29]

Critical incident stress management (CISM) has been conceptualised as a systematic approach to crisis that involvestrainingbeforeevents arise, anddebriefingafter theeventshaveoccurred.[30] This latter activity, psychological debriefing,is the component of critical incident stress management that has beenmost thoroughly studied. It consists of asingle-session intervention led by a trained professional, in which individuals or groups who have been recently exposed

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OVERVIEW

OverviewMental health response to disasters and other critical incidents

to a critical event review what happened and how they felt about it, as well as possible problems and symptoms thatmight arise in the future.

Several systematic reviews have been conducted to examine the effectiveness of CISM or psychological debriefing.[1][2] [24] [31] [32] [33] [34] The Cochrane review, first completed in 2001 and published online in 2002, concluded thatthere was no evidence of a treatment effect.[32] The review recommended that psychological debriefing of individualsshould cease, and that the use of the technique in groups required further study. A contemporary review of the literaturehas concluded that CISM is ineffective inmost instances andmight be harmful for vulnerable populations.[1] In practice,some people affected by disaster often appreciate the immediate chance to share their experiences in a debriefing,whether individually or as a group, and thus survivors or responders can and probably should be offered the opportunityto voluntarily participate. Psychological debriefings shouldnotbemandatory.Groupdebriefings shouldbeashomogenousas possible to avoid exposing members to new traumamaterial.

A limited number of studies have looked at debriefing in children.[35] Definitive conclusions about the benefits ofinterventions are lacking in these studies due tomethodological limitations. Anecdotal evidence suggests that debriefingfor children should be voluntary (with the consent of parents and caregivers), should not occur immediately after theincident, and should avoid re-traumatising by reliving experiences of the disaster.

Management of long-termmental health problems

An in-depth discussion of the long-term treatment of disaster-related disorders, such as PTSD, major depression, andalcohol use disorder,[10] is beyond the scope of this chapter. However, we will briefly review treatment of PTSD since itis likely the trauma-relateddisorderwithwhichGPsandevenmanymental healthprofessionals are least familiar. Cognitivebehavioral therapy (CBT) is the most widely supported intervention for PTSD, and many related psychotherapies arederivatives of it, such as cognitive processing therapy and prolonged exposure therapy.[18] [24] [29] [34] [36] [37] CBT isa time-limited therapy that addresses very specific thoughts andbehaviours related to the traumatic event. CBT specificallyexamines the dysfunctional beliefs and behaviours thatmay have predisposed a survivor to developing a condition suchas PTSD.

Eye-movement desensitisation and re-processing (EMDR) is an intervention that asks trauma survivors tomake back andforth eyemovements or listen to bilateral tones as they focus on traumaticmemories; it is recommended inmany PTSDalgorithms.[34] [37] Althoughmuch debate remains about whether the eye movements add anything to the therapy,they are theorised to aid in the processing and de-intensification of the memories. It has been used in many settings,including in work with Syrian refugees who had PTSD.[18] [38]

There is some evidence to support the use of CBT as part of the overall treatment of children with ongoing symptomsfrom exposure to non-relational trauma.[39] [40] One small sample study showed efficacy for short-term CBT use over ageneral supportive approach in adolescent victims of a natural disaster who lost their parents and developed PTSD ormajor depression.[41] Potential benefit has been identified for school-based psychotherapy interventions, which includeCBT features, for children exposed to traumatic events.[39] [40]

There are conflicting recommendations about the primacy of medication treatments for symptoms of PTSD. The UK'sNational Institute for Health and Care Excellence (NICE) 2006 guidelines state that drug treatment should not be usedas a routine first-line treatment for adults with post-traumatic stress disorder (PTSD), and recommend drug therapy forthose who do not benefit from psychological therapy.[42] The World Health Organization’s mhGAP humanitarianinterventionguide likewise suggests only using antidepressantmedications, suchas selective serotoninuptake inhibitors(SSRIs) and tricyclic anti-depressants, if psychotherapies (such as CBT or EMDR) do not work or are unavailable (and alsoproscribe the use of any suchmedications in children).[29] On the other hand, the American Psychiatric Association’slast update of its clinical guidelines for PTSD in 2009 supports the use of SSRIs, as well as other antidepressants (at leastin non-combat-related PTSD) and other psychotropic medications (e.g., atypical antipsychotics and anti-adrenegricagents, such as prazosin).[37] The US Food and Drug Administration has approved two SSRIs for use in PTSD, sertralineandparoxetine.Altogether,PTSD (andespecially chronicPTSD) likely requiresasequenceorcombinationof trauma-focusedpsychotherapy andmedication.

Further sources of information include [The European Network for Traumatic Stress] and [EFPA: resources] .

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OverviewMental health response to disasters and other critical incidentsOVERVIEW

Role of systemsmanagement

It is crucial for mental health planning to be incorporated into pre-event planning, whether via professional societies,volunteer organisations, emergency operations agencies, or health departments. This requires much advocacy andpersistence on behalf of mental health professionals but ensures that, when a disaster occurs, mental health servicesare both included and integrated.

As each critical incident unfolds, groups need to assess the particular incident and respond to critical needs.[43] [44] [45]These activities require that groups collaborate to plan and carry out decisions. These actions dependon the functioningof many natural systems, including family systems, religious groups, schools, and businesses. These groups extend wellbeyond the circle of first responders, for whom critical incident stress management was developed. Supporting andcoordinating this complex array of social organisations, most of which want to contribute, is a central role of health andpublic health authorities both inplanning for andacutely responding to critical incidents.[43]Oneexemplary cross-agencymental health response was the Resilience Coalition, which arose after Hurricane Katrina.[46]

The management of systems follows a set of activities similar to those in the Psychological First Aid Field OperationsGuide. However, these activities are directed at creating a census of social groups, identifying their normal roles, andgetting the groups to perform both their normal roles and the new roles they need to fulfil to recover from trauma.

Inkeepingwith thepragmatic toneofpsychological first aid, healthcareproviders shouldbyextensionconsider themselveshumanitarians first and healthcare providers second. Likewise, disaster mental health professionals should considerthemselves humanitarians first, healthcare providers second, and mental health professionals third.

Next steps

The team that developed the Psychological First Aid Field Operations Guide advocates research on positive adaptationandcopingamongsurvivors.[47] This is amarkedshift fromthesymptom-ordiagnosis-orientated research thatdominatesthe disaster literature. The hypothesis is that promoting a sense of safety and speeding a return to comfort will helppeople feel that they are individually and collectively powerful and competent. It should also build skills so that peopleare better prepared for coping with other life problems, buoyed by their resilience rather than enfeebled by past tragedy.Novel research paradigms will be needed to test these interesting hypotheses. Screening instruments appear to have amajor role to play in helping to identify people at high risk of illness and in need of treatment. These instruments willneed to be refined for use across populations and after many kinds of event. Finally, there remains a need for moreevidence to guide management of both the acute and long-term sequelae of traumatic events.

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OVERVIEW

OverviewMental health response to disasters and other critical incidents

Online resources

1. The European Network for Traumatic Stress (external link)

2. EFPA: resources (external link)

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Online resourcesMental health response to disasters and other critical incidentsONLINERESO

URCES

Key articles

• Sever MS, Vanholder R; RDRTF of ISN Work Group on Recommendations for the Management of Crush Victims inMass Disasters. Recommendation for themanagement of crush victims inmass disasters. Nephrol Dial Transplant.2012;27(suppl 1):i1-i67. Full text Abstract

• Bisson JI, TavakolyB,WitteveenAB, et al. TENTSguidelines: developmentofpost-disasterpsychosocial careguidelinesthrough a Delphi process. Br J Psychiatry. 2010;196:69-74. Full text Abstract

• World Health Organization. Psychological first aid: guide for fieldworkers. Geneva: WHO; 2011. Full text

• North CS, Pfefferbaum B. Mental health response to community disasters: a systematic review. JAMA.2013;310:507-518. Abstract

• Gartlehner G, Forneris CA, Brownley KA, et al. Interventions for the prevention of posttraumatic stress disorder(PTSD) in adults after exposure topsychological trauma.Rockville (MD): Agency forHealthcareResearchandQuality(US); 2013. Full text Abstract

• Forneris CA, Gartlehner G, Brownley KA, et al. Interventions to prevent post-traumatic stress disorder: a systematicreview. Am J Prev Med. 2013;44:635-650. Full text Abstract

• National Institute for Health and Care Excellence. Post-traumatic stress disorder: The management of PTSD inadults and children in primary and secondary care. March 2005. http://www.nice.org.uk (last accessed 29 March2017). Full text

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DisclaimerMental health response to disasters and other critical incidents

Contributors:

// Authors:

Craig L. Katz, MD

Clinical Professor of Psychiatry and Medical EducationDirector, Program in Global Mental Health , Icahn School of Medicine at Mount Sinai, New York City, NYDISCLOSURES: CLK is a consultant for Advanced Recovery Systems in the development and opening of a facility for traumatizedfirefighters. CLK is an author of references cited in this topic.

// Acknowledgements:

Professor Craig L. Katz would like to gratefully acknowledge Dr R. Gregg Dwyer and Dr Mindy T. Fullilove, previous contributors tothis monograph.DISCLOSURES:MTF is the author of some studies referenced in thismonograph. RGDdeclares that hehas no competing interests.

// Peer Reviewers:

Carol North, MD

The Nancy and Ray L. Hunt Chair in Crisis Psychiatry and Professor of PsychiatryDirector, Division of Trauma and Disaster, The University of Texas Southwestern Medical Center Dallas, TXDISCLOSURES: CN is the author of some studies referenced in this topic.

Chris Brewin, PhD

Professor of Clinical PsychologyResearch Department of Clinical, Educational and Health Psychology, University College, London, UKDISCLOSURES: CB is the author of one study referenced in this monograph.