Adult Disaster Psychiatry

In the 7 years since the 9-11 attacks and the 4 years since Hurricane Katrina, an increased interest in the psychiatric sequelae to disasters has developed in the field of American psychiatry. This has helped the field to develop greater sophistication in epidemiology and in the treatment of individuals affected by disasters.

The field of disaster psychiatry, itself, needs to be understood in relation to other areas of psychiatry, such as trauma psychiatry and military psychiatry. Disasters can be defined as mass traumas that affect a whole community. Disaster psychiatry is not simply the study of posttraumatic stress disorder (PTSD). Although PTSD occurs at high rates after traumas (1), other disorders also may occur in the aftermath of traumas as described in the Epidemiology section below. Conversely, the study of PTSD includes cases that are the result of individual traumas rather than disasters. Because disasters affect whole communities, practitioners of disaster psychiatry must remain aware of system issues and group dynamics as well as a broader array of social, political, and cultural issues. For example, the tremendous national impact of the 9-11 attacks may alter available social supports for and clinicians' attitudes toward survivors in ways that are profoundly different from those for patients who experienced individual traumas (2).

Because the military is a community that is vulnerable to mass trauma during war, military psychiatry is closely related to disaster psychiatry and developments in military psychiatry such as debriefing have informed clinical practice in disaster psychiatry (3). However, disaster psychiatry differs from military psychiatry in a variety of ways. Civilian populations will include children and elderly populations that are not routinely a part of military activities. In the United States, the military is a self-selected population that forms a culture with specific expectations about exposure to trauma and the normative response to those traumas that may differ tremendously from those of domestic civilian populations (4). In addition, there is no structure equivalent to the military hierarchy in civilian life. Interventions, such as the universal screening of all returning active-duty military personnel from a war, are not easily translated to civilian disasters such as the 9-11 attacks in Manhattan because individual autonomy in civilian society would limit such mandates. Thus, different system issues and outreach modalities need to be considered in civilian disasters (5).

EPIDEMIOLOGY

PTSD is the most commonly described reaction to disasters with major depressive disorder being the second most studied (6). In addition, to major depressive disorder and PTSD, the new onset of other anxiety disorders, notably generalized anxiety disorder and panic disorder, have been noted after disasters (7). Medically unexplained physical symptoms or somatization are commonly described after disasters although the methodological limitations of existing studies limits our ability to estimate the incidence of somatoform disorders (6, 8, 9). Although several studies have suggested that the rate of use of addictive substances increases after a disaster (10, 11), researchers who have looked systematically for new-onset substance abuse and dependence have found relatively few new cases of these disorders with onset after the disaster (12, 13). The rates of psychopathology vary notably between different disasters (12, 14) and between different populations studied after the same disaster (12, 15). A large review of disasters suggests that intentional man-made disasters (such as terrorist attacks) may have a higher impact than disasters that are the result of unintentional human activity (such as mass transportation accidents), which in turn may have a higher impact than natural disasters (such as floods, earthquakes, and tornados) (6). Although it is intuitive that there should be a psychological impact from malicious intent, exceptions to this generalization have been identified (16), which is not surprising because large natural disasters, such as hurricanes, can extend thousands of miles and can directly threaten the lives of millions of people, whereas some intentional man-made disasters (such as a workplace shooting) may have a much more circumscribed population that is directly affected.

Cultural beliefs about normative responses to death and trauma, varying attitudes about help-seeking behavior from general disaster relief to specific mental health services, and the role of culture-specific healing rituals and culture-specific idioms of distress all affect the response to disasters (17, 18). Although the cultural variation in responses to disasters has lead some to question whether PTSD, itself, is a culture-bound syndrome (18), studies from Asia (19), Africa (7), and Europe (20) have shown estimated rates of PTSD that are within the range noted in disasters in the United States of America. The rate of PTSD in those exposed to trauma is also known to be affected by the duration of exposure to the trauma, the severity of the trauma, and physical proximity (DSM-IV-TR), which inevitably differs between disasters and between individuals affected by the same disaster. Other factors that may affect the psychological impact of a disaster are the degree to which participants may have control over future impact (21) and their prior exposure to other traumas (22, 23).

POPULATIONS REQUIRING SPECIAL ATTENTION AFTER DISASTERS

Women have a higher rate of PTSD after a disaster (6, 24) and have higher rates of major depressive disorder and all anxiety disorders in the general population (25) and, thus, require special attention after a disaster. Although different minority racial and ethnic groups have been identified as having higher rates of psychopathology after different disasters (26–28), differences in baseline rates of prior trauma, differences in rate of exposure, and differences in subsequent support make it difficult to conclude that any group is at inherent risk other than to note that, generally, members of minority ethnic groups fare worse than members of the majority ethnic group (6).

Although new onset psychosis or addictive disorders are not common after disasters, disruption of existing mental health and substance abuse treatment (29) make these populations vulnerable after a disaster. Individuals with serious mental illness such as schizophrenia may be especially vulnerable after a disaster (30, 31) because of limited social support and higher rates of prior trauma. Thus, in practice, disaster psychiatric services need to be prepared to treat individuals with preexisting conditions (32).

Although there have been contradictory findings about whether advanced age is a risk factor or a protective factor after a disaster (6, 33), because of the decreased mobility of many elderly individuals, this population may be especially vulnerable to disasters that require evacuations, such as the evacuation of New Orleans, La., before Hurricane Katrina. In addition, outreach services may be necessary as part of the response to the disaster to address the needs of homebound elderly individuals.

Aside from disaster survivors, responders to disasters may be vulnerable to developing psychopathological problems, including acute stress disorder, PTSD, and depression (34) and the rates of these problems in responders may vary from those in survivors (15). This fact should not be surprising because responders may have a different level of exposure, sometimes witnessing the carnage of disaster sites for much longer than direct survivors. In addition, whereas disasters can be considered “equal opportunity” traumas that affect a relatively random population, individuals who chose to become responders to disasters, such as policeman, fireman, and military personnel, are a self-selected group who may differ from the general population in a variety of demographic and psychological factors, suggesting the need for specialized interventions that may be culturally acceptable within this group (35). Health care workers and mental health care workers are not immune to the psychological effects of a disaster (36–40) and a clinically useful literature has developed for overlapping concepts such as “countertransference to trauma,” “burnout,” and “vicarious traumatization” (41, 42). However, it is important to recognize that experience of distress and dysfunction after working with traumatized populations would be unlikely to qualify as PTSD unless one loosely interprets Criterion A of PTSD, which requires that an individual “experiences, witnesses or is confronted with life endangerment, death, or serious injury or threat to self or others; and the individual responds to the experience with feelings of intense fear, helplessness, or horror” (DSM-IV-TR).

TREATMENT STRATEGIES AND EVIDENCE

EARLY INTERVENTIONS

Because of the community-level impact of disasters, both community-level interventions and individual treatments need to be considered when responding to disasters. On a community level, a recent review suggested that mass panic may be less likely than previously assumed (43). The study of Risk Communication that has developed within the field of public health has received increased attention in its relationship to disasters since 9-11. A study of the evacuation of New Orleans, LA, after Hurricane Katrina demonstrated that different populations may respond differently to safety messages and that therefore greater attention needs to be paid before disasters to identify populations that may be especially vulnerable (44). In the specific case of Hurricane Katrina, a history of mistrust of government intentions toward minority communities may have hindered the calls for evacuation.

Although the observed level of distress and the urge to help may be tremendous immediately after a disaster, there are challenges in conducting systematic research on such interventions (45). Nonetheless, the provision of psychiatric services to survivors of disasters can serve an important humanitarian function, responding to a need for immediate symptomatic relief and for continuity of care for those with prior diagnoses (32). In the absence of definitive early treatments, the National Institute of Mental Health has endorsed general principles that emphasize voluntary participation in treatment, a hierarchy of needs that focuses on basic issues of survival, food, and shelter before shifting to psychological issues and creating expectations of resiliency (46). Another expert panel has recommended an overlapping set of principles for immediate interventions, emphasizing that clinicians should promote: a sense of safety, calming, a sense of self-efficacy and community efficacy, connectedness, and hope (47). To remain effective when working after a disaster, clinicians must remain attentive to their emotional reactions to the event and the risk of burnout (36).

LATER INTERVENTIONS

Interventions for individuals who meet diagnostic criteria (which requires at least 2 weeks after a disaster for new-onset major depressive disorder and 4 weeks after a disaster for new-onset PTSD), have a stronger evidence base. Despite limitations in the data (48, 49), selective serotonin reuptake inhibitors remain a first-line treatment for PTSD (48). Cognitive and behavioral therapy, specifically exposure therapy, has been studied in general populations affected by PTSD (50) and in those with PTSD after a disaster (51).

QUESTIONS AND CONTROVERSY

The role of psychological debriefings after disasters remains controversial. Psychological debriefings may vary tremendously between different models and studies but are often one-time interventions, usually practiced in group settings to review the experience of individuals affected by a trauma with the goal of preventing psychological sequelae. Although this modality has spread widely from its origins in the military (3) and some evidence has been found to support its efficacy (52), others have concluded that this intervention may do more harm than good (53). Some of these discrepant conclusions may be resolved, if future researchers can refine the specific indications and contraindications (54). Research so far suggests that debriefing should not be mandatory and is more appropriate for groups that work as teams.

Eye movement desensitization and reprocessing (EMDR) is a psychotherapeutic intervention whose original premise was the notion that ocular movements can affect the processing of anxiety (55). The popularity of this intervention has grown tremendously over the last two decades, but the actual effect of ocular movements has been disputed, raising questions about the differences between EMDR and exposure therapy (55, 56). Nonetheless, EMDR appears to have efficacy comparable to that of cognitive behavior therapy (50), and larger head-to-head studies will be required.

Despite a retraction of an earlier finding of elevated rates of suicide after natural disasters (57), concerns about an epidemic of suicide remain a common concern after disasters (58, 59). Contrary to this popular belief, Kessler et al. (60) found an unexpectedly low rate of suicide despite a high rate of mental illness in populations affected by Hurricane Katrina, suggesting that there are protective factors after disasters.

RECOMMENDATIONS

Although this review demonstrates the need for psychiatric care after disasters, it is important for psychiatrists to resist the urge to respond as individuals. There is a complex hierarchy of organizations involved in most disaster responses and to be effective it is important for psychiatrists to respond within these established systems (5). Failure to do this can exacerbate the chaos inherent in disasters owing to poor coordination of scarce resources. In addition, overeager clinicians with good intentions can be misperceived as voyeuristic, sensation-seeking, or opportunistic.

Evaluations of individuals who are affected by disasters should include all the elements of a standard psychiatric evaluation with special attention to the degree of exposure to trauma (including length of exposure, proximity, experiences of injury, and experiences of destruction of property), symptoms of PTSD, other anxiety disorders, and major depressive disorder, past psychiatric history (especially history of trauma, PTSD, and depression and anxiety disorders), current social supports, and other current stressors (36). Although it is unlikely that individuals will develop a new onset of substance use disorders (see Epidemiology section above), because addictive disorders are prevalent in the general population, especially in the United States (61), many individuals exposed to disasters may be vulnerable to exacerbation or relapse, and therefore it is important to evaluate and treat substance use disorders in these settings.

During the first days to weeks after a disaster, individuals may be treated for exacerbations or relapse of prior conditions or may require symptomatic relief for anxiety or insomnia. Use of anxiolytics and hypnotics during this time period should be time-limited (62). Prophylactic medications for the prevention of new-onset PTSD or major depressive disorder is not the current standard of care, but individuals who have significant symptoms of these disorders in the immediate aftermath of disasters should be followed more closely.

When individuals do meet the criteria for PTSD or major depressive disorder, selective serotonin reuptake inhibitors and cognitive behavior therapy should be considered first-line treatments. Because of high rates of comorbidity (12), it is important for clinicians to track and treat each of the different psychiatric disorders identified after a disaster.

By following these recommendations, psychiatrists have an opportunity to help alleviate monumental suffering. Because disasters extend beyond an individual experience to become a larger cultural force, disaster psychiatry offers our profession a rare opportunity to look at a bigger picture. This growing fund of knowledge is the contribution psychiatry can give to the larger society as we grapple with these powerful events.