by Anthony T. Ng, MD

I lost everything when the hurricane came. . . My house got flooded and all my belongings are gone. . . The photo of my wife was all that I had left of her. . . I cry every night, thinking about how I lost everything. . . My whole life is in that house. . . I can't sleep. . . I can't eat. . . I can't even think straight. . . I don't have any interest in doing anything anymore. . . I stay to myself. . . I am so hopeless about my situation all the time that I sometimes wish this will just all end. . . My community is totally devastated. . . My neighbors lost everything too. . . We have not been able to get the help we need after this disaster. . . I just don’t know how we can rebuild from this.

Psychiatrists often hear remarks such as the above in the aftermath of large scale traumatic events. These words reveal how the suffering can be personal as well as collective and can lead to tremendous psychiatric distress affecting individuals and the community at large.

This has been apparent in the past several years as we witnessed major disasters, man-made and natural, including terrorist attacks on September 11th, and bombings in London and Madrid; Hurricane Katrina and Asian Tsunamis; and the more recent collapse of a bridge in Minnesota, a mine in Utah, and an earthquake in Peru.These events often cause significant suffering, death, injury and the displacement of people, as well as potential widespread damage and interruption to the communities involved.

For a long time, the focus within psychiatry was the identification and management of individuals who developed disorders after disasters. Extensive research, including studies conducted by Sandro Galea about September 11th and Ron Kessler about Hurricane Katrina, address the tolls from these disasters and other large-scale public health emergencies leading to increased rates of Post-Traumatic Stress Disorder, Major Depression, and Anxiety Disorders.

Unlike traditional psychiatry which works with individuals, disaster psychiatry aims to promote individual and community resilience. That has required a shift in paradigm.

A report from the Institute of Medicine in 2003 on the Psychological Consequences of Terrorism indicated that individuals are only part of the overall mental health sequelae to mass trauma. The stress of a disaster can influence how individuals relate to their communities, including how they follow through with evacuations, as was evident in September 11th and Hurricane Katrina, or how they seek medical care such as vaccination, or quarantine, as may occur in a potential pandemic flu outbreak.

After a disaster, changes in routines, changes in travel, and changes in how people see their surroundings begin to unfold as they assess their own situation and that of their communities. As noted in the above selection of disaster-victim responses, many do not know "how we can rebuild from this." New coping behaviors are required. Some people develop closer relationships with friends and family, enjoy life more, and try to give to the community by volunteering. But maladaptive coping behaviors also occur. Some people become argumentative, smoke or drink more, or use illicit drugs. They may overwork as a way to avoid dealing with stress in their lives. Each of these behaviors, or combinations of them, have public health implications even if people do not reach the point of seeking psychiatric care.

The field has benefited from The Center for Traumatic Stress Studies of the Uniformed Services School of Medicine and the Veterans Administration’s National Center for Post Traumatic Stress Disorder. They have focused on soldiers without a psychiatric history but who endured distressful symptoms due to sudden or chronic trauma such as combat.

In fact, many of the current concepts of disaster psychiatry have evolved in the last decade from the military focus on interventions for soldiers who were affected by a traumatic event. The goal is to reach them as soon as possible, and it carries an expectation of recovery.

Disasters create chaos leading to disruptions in social structures and the movement of large numbers of people. While psychiatric problems resulting from disaster and mass trauma have been well documented, research regarding specific individual or community-wide interventions have remained sparse and difficult. What evidence we have comes from case studies and anecdotal findings from past disaster experiences, disaster victims' feedback (such as the above), expert consensus findings, and inference of certain interventions from other types of trauma treatment. For example, cognitive behavioral therapy (CBT), which works to correct maladaptive behavior, has been widely endorsed as a potential intervention as it is by the far the most studied intervention in trauma and disaster. It has been shown to be effective in dealing with the psychiatric trauma from motor vehicle accidents or various types of abuses. CBT also been shown to lessen secondary traumatization faced by first responders in both their daily work and in disaster situations.

One modality that helps individuals focus on dealing with individual and basic community needs, Psychological First Aid (PFA), has been shown to be an effective intervention to reduce stress in the early phases after a disaster and plan for basic needs -- food, water, and shelter – later on. Additionally, PFA helps support and inform people about potential mental health issues that may arise from their traumatic exposure.

Disaster psychiatry also increases awareness about how psychiatric distress can influence response and recovery efforts. For example, individuals who are too distressed may not be able to follow through obtaining the resources they need from the American Red Cross or FEMA.

Not everybody exposed to a disaster will require psychiatric intervention, as indicated by studies of “population resilience” After Hurricane Katrina, as Kessler has shown, many individuals who were affected by the disaster expressed positive feelings despite early psychiatric distress. Such positive responses included feeling better about one’s self or family, a renewed faith and spirituality, or finding deeper meaning in life. Some disaster mental health researchers have described such resilience as “post-traumatic” growth.

In addition to work on the community level, disaster psychiatry has an important role in the advocacy of mental health in planning for response and recovery. Here disaster psychiatry brings awareness that communities can suffer long term consequences after the actual event. The collapse of a local infrastructure means people do not always know where to turn for help, how to obtain legal documents or financial help to reconstruct their work or their homes. Grief becomes an issue and an important part of disaster psychiatry promotes the normal processing of grief by mobilizing support which can be hard to come by after a disaster. Uncoordinated responses by agencies can increase anxiety and stress for individuals and communities.

Non-disaster related studies have shown that depression, for example, can reduce job productivity, and increase sick days and staff turnovers. All these can be costly to individuals, or their employers, and also society as a whole. Therefore, effective disaster responses must involve coordination between all agencies and disciplines and most effective when it is integrated into the planning process.

Undoubtedly disaster psychiatry has gained greater significance in the minds of the psychiatric community and disaster planners. However, there still needs to be more understanding of how it can help prepare populations for disasters to facilitate and to promote community resilience. Disaster psychiatry needs to collaborate with decision- and policy-makers on behalf of a public health approach. For example, it is important for disaster psychiatry to anticipate how the public might respond to a potential pandemic flu outbreak. Will there be plans for evacuation, for allocation of medical resources, and clear communication so the public will know what to do and how to do it? Anticipating these issues reduces psychiatric distress, and that results in less panic, more access, and fewer shortages real and imagined.

It is vital that the growing discipline of disaster psychiatry be integrated into the general disaster structure to ensure the likelihood of a comprehensive and robust disaster mitigation, response and recovery.

Anthony T. Ng, MD is the director of Mannanin Healthcare, LLC, an emergency medical management consulting firm. He is on the faculty at the Uniformed Services School of Medicine and George Washington University School of Medicine and is the past chair of the American Psychiatric Association Committee on Psychiatric Dimensions of Disaster. He has participated in disaster responses to the September 11th World Trade Center attacks, the anthrax attacks, aviation disasters, and Hurricanes Rita and Katrina. He has written extensively in the area of disaster psychiatry.