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Disaster Mental and Behavioral Health

Dori B. Reissman, Merritt D. Schreiber, James M. Shultz,

and Robert J. Ursano

OVERVIEW

Communities exposed to disasters experience multiple traumatic events including threats to life, loss of prop- erty, exposure to death, and often economic devastation. Disasters by definition overwhelm institutions, health care, and social resources and require from months to years for both individuals and communities to recover.1

In the aftermath of disasters, human-caused or otherwise, a range of behaviors and symptoms emerge with profound clinical and population-level public health implications. A number of terms have been used to describe the social, psychological, and emo- tional health of affected populations in the aftermath of disas- ters and acts of terrorism. “Behavioral and mental health” has emerged as the phrase meant to embrace the broad range of human reactions to disasters. The use of the term “behavior” captures the actions people take to reduce perceived threats to safety, health, and well-being. These coping behaviors also have social and emotional impacts that may alter the extent of loss and change triggered by the disaster or its aftermath.

Characteristics of the disaster event may greatly increase the stress experienced, such as lack of familiarity with the prevailing hazard (e.g., anthrax in the U.S. mail in 2001), use of fear as a weapon (i.e., terrorism), intensity of impact (e.g., degree of direct exposure to harm, loss, and change), predictability of the event (e.g., no warning, inability to avoid, unclear targets, protracted or stuttering course), or caused by human action (purposeful intent to harm vs. accidental). This chapter describes the 1) range and timeline of typical reactions, 2) approaches for screening, triage, and referral, 3) preventing and managing psychological injuries, and 4) integrated strategies to support disaster responders.

RANGE AND TIMELINE OF TYPICAL REACTIONS

Disasters and acts of terrorism produce a spectrum of common physiological, psychological, social, behavioral, emotional, cog- nitive, and spiritual reactions (see Table 7.1 for adult and Table 7.2 for child reactions). Broadly speaking these involve anxi-

ety (notably posttraumatic stress), affective symptoms (notably depression), and medically unexplained symptoms involving multiple organ systems.2,3 The Institute of Medicine (IOM) Committee on Psychological Aspects of Terrorism provided a useful framework capturing a range of social and emotional impacts to help disaster and emergency planners prepare for and manage anticipated clinical and population-level effects across the life cycle of the event (including pre-event, event response, and recovery phases).4 In their report, the IOM committee illus- trates three overarching, time-phased, and interrelated aspects of population-level impact: 1) distress responses (acute and short term); 2) changes in behavior; and 3) clinically significant psychi- atric disorders and impairment. Direct disaster exposure includes the following: 1) serious injury; 2) traumatic bereavement (e.g., loss of a spouse, child, or parent); 3) loss of home or other critical resources (e.g., social support networks); 4) witnessing severe or mutilating injury or death of others; 5) perceiving one’s life to be in danger; and 6) managing prolonged uncertainties about imminent threats to health, safety, and well-being.1,2,5

Distress Reactions

For people who are directly exposed to a disaster, acute posttrau- matic reactions such as hypervigilance, difficulty sleeping, and feelings of anxiety, event-specific fears, anger or rage, and vul- nerability, are prominent and tend to emerge quite early. Recov- ery can be rapid for most, slower for others, or for some, may not occur at all. Chronic performance problems may develop at work, school (children), home (family roles), or socially. Aside from those directly exposed to the disaster, many other individu- als may be traumatized by the event either through close ties with directly affected persons, intrusive and high-intensity media cov- erage, or cascading changes (e.g., business closure, destruction of local facilities, parks, or neighborhoods) evoked by the disaster. For example, days after the September 11, 2001 terrorist attacks in the U.S., a national survey found that 44% of adult respondents had one or more symptoms consistent with posttraumatic stress disorder (PTSD), and one third of respondents with children reported their children to have at least one traumatic stress symp- tom.6 Psychological distress may extend broadly to residents

103 Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-08 12:22:42.

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104 ■ D O R I B. RE I S S M A N, ME R R I T T D. SC H R E I B E R, JA M E S M. SH U LT Z, A N D RO B E RT J. UR S A N O

Table 7.1: Common Adult Responses to Disasters and Traumatic Events

Physiological Behavioral and Cognitive and Responses Emotional Responses Spiritual Responses

Fatigue Anxiety, fear Memory problems

Nausea, vomiting Grief, guilt, self-doubt, sadness Calculation difficulties

Fine motor tremors, tics, paresthesias Irritability, anger (sometimes displaced), resentment, increased conflicts with friends/family

Confusion in general and/or confusing trivial with major issues

Chest pain, choking, or smothering sensation

Feeling overwhelmed, hopeless, despair, depressed

Concentration problems, distractibility

Nonspecific joint or body aches or pain Anticipation of harm to self or others; isolation or withdrawal

Crisis of faith, anger at God, questioning basic religious beliefs

Profuse sweating Changes in usual eating, sleeping patterns

Recurring dreams or nightmares

Dizziness Gait change Decision-making difficulties, easily confused

Gastrointestinal upset (diarrhea or constipation, pain)

Hypervigilance, startle reactions Preoccupation with disaster events

Racing pulse, heart palpitations Crying easily, mood swings Lessened ability to handle complexities

Headaches Gallows humor Fear of crowds, strangers, or being left alone

Environmental tolerance (temperature, sound, smell)

Poor performance of usual roles (home, work, social)

Anomia

Regression to less mature or risky behaviors

Slowed rate of thinking, speech difficulties

Ritualistic behavior

Table 7.2: Age-related Responses to Disasters by Children

Children of All Ages Preschool Age (1–5 y) Early Childhood (5–11 y) Adolescence (12–14 y)

Anxiety and irritability Changes in eating habits Increased aggressiveness Abandonment of chores, schoolwork, and other prior responsibilities

Clinging, fear of strangers Changes in sleeping habits Changes in eating/sleeping Disruptiveness at home or in the classroom

Fear of separation, being alone Clinging to parent Difficulty concentrating Experimentation with high-risk behaviors such as drinking or drug use

Head, stomach, or other aches Disobedience Regression to earlier behavior Vigorous competition for attention from parents and teachers

Increased shyness or aggressiveness

Fear of animals, the dark, “monsters”

Competing more for the attention of parents

Resisting authority

Nervousness about the future Hyperactivity Fear of going to school, the dark, “monsters”

Regression to immature behavior Speech difficulties Drop in school performance

Reluctance to go to school Regression to earlier behavior (thumbsucking, bedwetting)

Desire to sleep with parents

Sadness and crying

Withdrawal

Worry, nightmares

Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-08 12:22:42.

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DI S A S T E R ME N TA L A N D BE H AV I O R A L HE A LT H ■ 105

and workers within affected communities and beyond (e.g., to the nation) by intense media coverage.7 From a developmental per- spective, children’s distress reactions are somewhat unique and embedded in the context of parental coping.8,9 These reactions may include regression from previously achieved developmen- tal milestones and the emergence of problems with separation, night-time behavior, or learning. Many disaster research stud- ies have observed nonspecific indicators of distress10,11 or per- ceived stress,12 demoralization,13 changes in world view,14 phys- ical health concerns,3,15–19 healthcare utilization, and changes in perceived safety and security.20

Changes in Behavior

A proportion of people exposed to disasters are affected to the point of changing their health-risk behaviors.4,21 In the immediate aftermath of a disaster or mass violence, individu- als may respond in adaptive, effective ways or they may make fear-based decisions, resulting in maladaptive behaviors. Indi- viduals exposed to terrorism and other disasters have been found to increase their use of alcohol, tobacco, and other drugs, especially those with preexisting alcohol use or other psychi- atric difficulties.22–24 Additionally, prior studies have noted a surge in demands for medical evaluation induced by a signif- icantly sized outbreak of infectious disease, or complicated by fear evoked by a mysterious or potentially toxic exposure. This surge in help-seeking behavior may merely be a consequence of the stress involved in managing uncertainty; however, the increased demand for medical evaluation can easily overwhelm local healthcare systems.25–28 Other reactive behaviors exert sig- nificant influence on health, safety, and well-being: these include driving at high speed without seatbelt restraint or under the influence of alcohol or illicit substances; poor lifestyle choices (e.g., no exercise, poor nutrition, and promiscuity); provocative and assaultive behavior; work absenteeism or declines in perfor- mance; poor decision-making; and reactive alterations in per- sonal family plans. Behavioral changes may emerge even when disasters threaten but fail to materialize (e.g., threats of more air- craft bombs in carry-on luggage; a menacing hurricane that shifts course and does not make landfall; the stigmatizing reactions of those in the U.S. facing the severe acute respiratory syndrome [SARS] epidemic).

STATE OF THE ART

Adherence to Public Health Measures

There is a wide gulf between desiring that the public behave in a certain manner and having this actually occur. The involvement of the public as a key strategic partner has only recently been described and is in need of serious attention.29 This highlights a critical disconnect in emergency planning efforts in that the behavioral aspect of adherence has not been adequately included in planning and scenario development.25,26,30,31 The degree to which adequate proportions of the population comply with or adhere to public health directives (e.g., quarantine, movement restrictions, mass prophylaxis, school closures, appropriate seek- ing of healthcare) may directly impact the success of public health and emergency medical response efforts. Numerous individual, group, and population-level behavioral changes may occur in response to all types of hazards that, in turn, have profound impacts on the success of public health emergency response

efforts, economic trends, and the resilience of a nation as a whole.

There appear to be “disaster myths” embedded within response plan assumptions across many levels of government.32

One such myth is that the public will “panic” (albeit, not defined) in response to emergencies. There has been significant concern and confusion about the term “mass panic,” aggravated by a lack of basic science to inform policy. It is actually uncommon for individuals to act without an underlying concern for others (i.e., totally self-focused or violent). In fact, neighbors or coworkers are most likely to be the “first responders” on the scene (for events with a scene), willing and able to help constructively and collec- tively.33 Although paniclike behavioral phenomena are rare, the potential for this reaction has been tied to

■ Beliefs that there is little chance of escape (e.g., engulfing fire in a crowded room)

■ Perceived high risk from event (e.g., running from a collaps- ing building)

■ Available, but limited, treatment resources ■ No perceived effective response ■ Significant loss of faith in authorities

Another, more recently prevailing view suggests that the public need only be clearly “instructed” by credible sources and they will comply. This perspective discounts the impact of a plethora of mediating factors and “tipping points” such as culture, spe- cial needs, or the impact of specific hazard perceptions of risk and protective actions.21,31,34 The potential massive impact of events contained in governmental planning scenarios requires deliberate attention to anticipate and mitigate predictable trig- gers of panic-like behavior at the population level. For example, evacuation orders in response to the Three Mile Island nuclear accident resulted in massive gridlock from surrounding areas that were not instructed to leave. Following the SCUD attacks in Israel, approximately 70% of hospital emergency department visits were tied to psychological factors including 230 (27%) indi- viduals who self-injected themselves with nerve agent antidote – even though they had not actually been exposed to a nerve agent, and 544 (44%) with admitting diagnoses of “acute stress reac- tions.”35 Although the evidence base is limited, prior experience, personal beliefs, and actions or beliefs shared by loved ones or local thought leaders are believed to greatly influence adherence behaviors.36 Additionally, the content of risk communication, trust or faith in social institutions, and a host of event- or risk- specific contextual features influence adherence to governmental directives for protective action from a population perspective.37

Governmental efforts directed at planning for pandemic influenza are beginning to address the potential for societal disruption and dysfunction, with attention directed at busi- ness and government operational continuity. Collective reactions may involve behaviors to demand, hoard or otherwise procure (in competition with public health channels) antiviral prophy- laxis or other perceived life-saving treatments. In some recent modeling studies of community measures to contain the spread of pandemic influenza, prompt closure of schools (requiring the active collaboration of public health, school districts and, notably, parents) resulted in a case rate reduction of approx- imately 14%. This represented the largest single reduction in rates of influenza, and this action led to a “decompression of the peak burden.”38 Together with other strategies such as social dis- tancing, a 40% reduction in peak burden was achieved. Clearly,

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strategies to enhance behavioral compliance with community mitigation strategies may significantly reduce the impact of the next influenza pandemic.

Understanding the impact of population compliance or adherence to instruction in controlling the spread of infectious diseases is informed by studies of those quarantined due to the SARS outbreak. Approximately 30% of those placed in even a rel- atively brief quarantine (up to 10 days) had symptoms of PTSD and depression.39 Key risk factors for developing these outcomes included the duration of quarantine and knowing someone or direct exposure to someone with a diagnosis of SARS. Compli- ance with quarantine in Toronto was associated with

■ Fear of loss of income while quarantined ■ Inconsistencies in local application of quarantine from area

to area ■ Inconsistencies in monitoring of compliance ■ Logistical support (e.g., access to groceries, transportation of

family members)

Approximately 57% of Canadians neither in quarantine nor exposed directly in Toronto also had fears about acquiring the illness but did not report clinical levels of disorder. Taken col- lectively, the findings suggest that social distancing strategies used to contain disease resulted in pronounced behavioral health effects in the form of fears, isolation, stigma, and boredom, all of which negatively impacted compliance with quarantine and may be exportable to other scenarios. A practical implication for pub- lic health emergency response planning is that public acceptance and adherence is greater in voluntary as opposed to mandatory strategies and where income protections are provided for those in quarantine.36 These data are from the United States however, and effective strategies may vary in different countries with other cultural norms.

Management of Demand Surge Acute demand surges for medical evaluation have been

observed in reaction to disasters, mass violence, and traumatic events. The nature of the health complaints appears to be related to: 1) toxic exposure, 2) specific symptoms related to the current health threat, 3) exacerbations of underlying chronic disease (in part due to lack of access to regular medications including psy- chiatric drugs), or 4) troubling and nonspecific symptoms that may be related to distress or fear. This last issue often leads to dissatisfying provider–patient relations.23 The proper triage and management of this demand surge has critical bearing on the following: 1) systemic ability to provide timely life-saving inter- ventions for those with acute medical/surgical needs; 2) pre- vention of chronic psychiatric disorders and life dysfunction; 3) organizational chaos and cascading inefficiencies; 4) health- care staff stress and burnout; and 5) customer (community) satisfaction. Nonspecific health complaints associated with dis- asters and mass violence have been called “multiple unexplained physical symptoms” or “disaster somatization reactions.”3,9 Peo- ple with multiple unexplained physical symptoms or disaster somatization reactions, in special circumstances, outnumbered direct medical casualties with ratios as high as 1,700:1.3 Fol- lowing a nonionizing radiation event in Brazil with quite lim- ited exposure in which four people died, approximately 130,000 unexposed individuals presented acutely to be screened for radia- tion illness and approximately 5,000 displayed symptoms of acute

radiation sickness. Other collective demand surges may emerge in attempts to obtain protective equipment (masks, gloves) or medical prophylaxis (e.g., distribution of pharmaceutical stock- piles), especially if there is high mortality, limited availability of effective treatment, or little warning and short window of oppor- tunity for prophylaxis. Survey data conducted in November 2005 suggests “only 35% of the American public is confident in the health care system’s readiness to respond effectively to a deadly flu pandemic”.40 Furthermore, only 53% indicated that they feel “prepared for a natural disaster or weather emergency.” This highlights a need to better understand, integrate, and prepare for the emotional, behavioral, and social factors involved in demand surge and adherence to public health measures.

Psychiatric Dysfunction and Clinical Disorders A smaller but significant fraction of disaster-exposed persons

progress to incident or recurrent psychiatric illness. Norris and colleagues reviewed the disaster literature and summarized 225 studies pertaining to 132 distinct, acute, collectively experienced events with sudden onset that were quantitative in approach and published in English between 1981 and 2004.2 Assessments of symptoms consistent with clinical disorders such as PTSD, gen- eral anxiety, or depressive disorders were the most commonly published findings. It is important to consider the community- wide magnitude of mental and behavioral health needs to enable appropriate planning and resource allocation. Children and ado- lescents have been found to be among those at highest risk of adverse mental health outcomes, including PTSD, depression, disruptive behavioral disorders, impairments in learning, and disaster-specific fears.8,9,41 In addition to costs for provision of mental health care, there are also healthcare costs associated specifically with PTSD.42

Understanding Community and Social Support Factors Empirical observations by various disaster experts were com-

piled to describe time-phased patterns of community-based responses after sudden-impact disasters such as hurricanes (or other extreme weather events), floods, or earthquakes.43

Although oversimplifying the underlying social tensions before a disaster strikes, this phased approach helps planners, response and recovery workers, and healthcare providers anticipate com- mon collective reactions based on elapsed time since the event. Inadequate disaster planning, preparedness, and response (e.g., Hurricanes Katrina, Rita, and Wilma) or faulty warning sys- tems (e.g., Indian Ocean tsunamis, 2004) exert lasting effects on the population’s overall psychosocial and behavioral health. Early in the aftermath of disasters (circumscribed in time and geography), people are mobilized to work together, with collec- tive action (i.e., prosocial behavior) including heroic acts and a bridging of social divides to help with search and rescue and early recovery activities. A period of disillusionment then emerges as barriers to rebuilding and economic and social recovery exacer- bate underlying social discord. Such barriers include inadequate insurance payouts, business relocations, loss of “neighborhood,” and perceived disparities in the distribution of public goods and services. The process of reconstruction or coming to terms with multiple layers and cycles of loss and change may take years, marked by anniversary reactions and other reminders of the traumatic events. The model captures useful phases for disas- ters within prescribed time periods and geography, but not all communities will proceed in the same fashion; phases may be

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skipped, prolonged, or revisited given the prevailing sociopolit- ical context. This model may not be useful for other types of disaster events, such as those caused by human action or inac- tion, (whether by accident or with the intention to cause harm) or those involving biological (e.g., SARS, pandemic influenza) or carcinogenic hazards.

Kaniasty and Norris analyzed social relationships as a critical determinant within communities impacted by disasters.44 These disaster researchers contend “disasters exert their adverse impact on emotional distress both directly and indirectly, through dis- ruptions of social relationships and loss of perceived social sup- port (p. 207).” For “natural” disasters, the initial mobilization of social support is following by a prolonged resource drain and expectations that are mismatched with postdisaster realities, and subsequently disrupt social support networks and cause loss of social resources. Kaniasty and Norris observed fragmented, polarized, mistrustful, and antagonistic community social pat- terns after “human-caused” disasters (technological) and high- lighted the conflicting and insufficient information surrounding such events. Psychosocial impacts are even more pronounced when harm is intentionally wreaked by human actions. Terror- ism occurring in the U.S. in 2001 resulted in: 1) anger, stigma, and violence sometimes under the guise of patriotism; 2) a his- torical reorganization of federal assets for homeland security;45

and 3) a multitude of alterations in travel, banking, and busi- ness practices. The next section will address the continuum of screening, triage, and referral for treatment.

APPROACHES FOR SCREENING, TRIAGE, AND REFERRAL

Many responses to trauma and disasters can be expected, but the following symptoms signal the need for further evaluation by mental health and other medical and human service professionals

■ Disorientation (dazed, memory loss, unable to give date/time or recall recent events)

■ Suicidal or homicidal thoughts, plans, actions ■ Domestic violence, child or elder abuse/neglect ■ Acute psychosis (hearing voices, seeing visions, delusional

thinking) ■ Inability to care for self (not eating, bathing, changing cloth-

ing, or handling daily life) ■ Severe anxiety (constantly on edge, restless, obsessive fear of

another disaster) ■ Problematic use of alcohol or drugs ■ Depression (pervasive feeling of hopelessness and despair,

withdrawal from others)

Longitudinal Incident Management From a population health perspective, time-limited distress

is very common and behavioral changes can influence health and safety outcomes over much longer periods of time.1,4,8 A smaller, yet significant, proportion of the affected population will be at risk for clinically relevant psychiatric disorders and dysfunction in various life roles. Psychiatric disorders require that symptoms and dysfunction persist for varying durations of time to meet diagnostic criteria. Risk for severe reactions and impairment will be predicted by a complex interaction among the following factors41

■ “Dose of exposure,” which is tied to individual experience (e.g., injury or illness, fearing death, and separation from family)

■ Death of loved ones (traumatic loss) ■ “Secondary stress,” such as impact of or worry about long-

term health risks, loss or difficulty with access to key services tied to housing, employment, insurance, stigma, reduced social support, and not being able to engage in valued pre- event activities (e.g., school, faith based, and sports)

■ History of mental illness or traumatic stress ■ Ensuing life stressors (job change, marriage/divorce, reloca-

tion, loss of loved ones, children moving away)

Relatively small increases in prevalence rates of psychiatric disor- ders within affected populations may result in a significant surge of absolute numbers of individuals requiring definitive mental health care and increase long-term demands on an already over- taxed and dysfunctional public mental health care system. This longitudinal model of impact suggests the need to align the deliv- ery of disaster mental health services along a more appropriate timeline of need. The prospect of a mass casualty event, with unparalleled behavioral health impacts over an extended period, would clearly tax traditional behavioral health approaches and unleash population-level psychological morbidity for many years to come. A combination of proactive risk communications, pub- lic health education and information campaigns, skill building for sustainable resilience, and rapid behavioral health triage and incident management hold the promise of mitigating the community-based behavioral health effects of an emerging global health threat such as pandemic influenza.5,31,41

In the absence of rapid triage and coordination between sys- tems, those with the greatest needs may not be located until clini- cal levels of distress and impairment have become entrenched.5,41

As large numbers of children move across different systems of care, inconsistent approaches to definition and assessment of acute need may further hamper critical provision of psycho- logical assistance and definitive care. For example, following the 1994 Northridge earthquake in California, many children at high risk due to intense event exposures were not identified until months and, sometimes, years later.46 These included chil- dren injured and/or trapped inside structures. Evidence from New York City also found that only 27% of children with severe or very severe posttraumatic reactions received any men- tal health care 4–5 months after the U.S. terrorist attacks of September 11, 2001.47 Acute-phase triage and incident manage- ment are critical because there is emerging evidence that cer- tain types of acute-phase interventions, applied early after the traumatic event, might afford a unique window of opportu- nity to interrupt the trajectory of risk, disorder, and impairment for those at high risk and who are already symptomatic.48,49

Mental health workers should apply timely, evidence-based stan- dards of postdisaster care to individuals at risk. Optimally, there needs to be a seamless system of triage, needs assessment, clinical care, and long-term surveillance for disaster-related mental and behavioral health.5,41

One new approach involves innovative partnerships among many entities including public health authorities; public infor- mation officers; emergency medical services; primary and advanced medical and behavioral health care facilities; medi- cal examiner and mortuary services; faith-based communities; schools; businesses; and nongovernmental relief organizations

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(e.g., International Red Cross). These “disaster systems of care” could help significantly mitigate adverse outcomes on a pop- ulation health scale if appropriately pre-event positioned and coordinated.5 This requires dynamic and continuous coordina- tion, communication, and resource (goods and services) delivery targeted to those at highest risk of adverse outcomes. A paradigm shift in disaster recovery planning is needed to manage the con- tinuum of risk and adverse outcomes over the extended course of recovery. An emerging incident management model (PsyS- tart) for disaster mental and behavioral health is composed of three major components to enable a common operational picture for participating entities and jurisdictions.5 The com- ponents include community-based “disaster systems of care,” a common system for incident/event-specific rapid triage, and information technology for near-real-time data linkage.41 In the PsyStart model, each participating system of care would use the same triage tag, which is based on objective evidence-informed exposure risk factors (not symptoms) for adverse mental health outcomes postdisaster. In field applications, the triage tags were found to predict appropriately PTSD and depression among exposed children in the Indian Ocean tsunami50 and the Laguna Beach, California wildfires.51 The rapid triage system can flexi- bly incorporate event- and hazard-specific exposure factors such as decontamination, mass prophylaxis or vaccination, shelter in place, quarantine, and/or evacuation. The triage data are used to inform incident managers of resources needs, match high-risk adults and children to available screening and clinical resources, and provide estimates of burden. In this way, stratified rapid triage data correspond to the concept of disaster medical triage and connect level of need with appropriate level of evidence- informed intervention throughout an extensive period of com- munity recovery.5,9

PREVENTING AND MANAGING PSYCHOLOGICAL INJURIES

Estimates of Disaster-related Behavioral Health Casualties

In catastrophic earthquakes that threaten many parts of the world, rates of disorder in the vulnerable child population have been found to be extremely high. For example, in a large earth- quake in Armenia, villages in which nearly half of the chil- dren died, the surviving children exhibited comorbid psychi- atric disorders approaching 90%.52 Severe flooding in Mexico caused extremely high levels of traumatic loss and infrastructure damage (home loss) and half the population had either PTSD or Major Depressive Disorder 6 months postevent. In recent surveillance of U.S. survivors of the September 11, 2001 terrorist attacks who were in collapsed and damaged buildings, 64% of the 5,383 building survivors reported new-onset depression, anxiety, or emotional problems after the event.53 Estimates of disorder within months of the event in New York City schools revealed an incidence of approximately 100,000 new mental health cases in school-aged children alone.54 In other catastrophic events, sig- nificant rates of behavioral health morbidity have been reported. For example, approximately half of those most severely impacted by Hurricane Katrina had clinically significant levels of distress, leading to U.S. federal funding requests for “enhanced services” beyond typically funded crisis counseling programs.

Psychological impact and resulting levels of psychiatric disor- ders may vary as a function of event characteristics, such as terror-

ism using weapons (biological, explosive, chemical, nuclear, or radiation) that can cause mass casualties and societal disruption.1

Weapons that involve sustained health risk over time may induce particularly pernicious mental and behavioral health morbidity on a population scale. Planning for mental and behavioral health- care needs must anticipate demand surges during acute-phase distress and behavioral reactive phase, followed by an extended trajectory of needs continuing and emerging throughout the duration of recovery, especially after mass casualty events.5,21

Basic Disaster Mental and Behavioral Health Intervention

Much of the initial on-site disaster mental health response focuses on 1) dampening anxiety and arousal by providing safety, comfort, and consolation; 2) assisting those directly affected to function effectively (reality testing and concrete problem solv- ing); and 3) providing clear guidance and information to ensure that basic individual and family needs are met (e.g., safety, medi- cal attention, water, food, shelter, clothing, essential medication, supervision of children and other dependents, and reunification of families).43,55 An extensive review of the evidence-based lit- erature was conducted, including two consensus development workshops to define key components of early intervention for survivors of mass violence55–57 Regardless of the type of disaster, it is important to continually assess needs, monitor the recovery environment, and provide outreach, screening, triage, and treat- ment services. The goal is to foster resilience, effective coping, and recovery.49,58

Early Intervention From a population health perspective, the following groups

stand to benefit from early intervention: 1) persons with direct disaster exposure (see “Approaches for Screening, Triage, and Referral”); 2) persons demonstrating extreme acute stress reac- tions (e.g., panic attacks or dissociative symptoms), extreme cognitive impairment, or prolonged and intense distressful emotions; and 3) persons having a prolonged inability to sleep.1,4,9,55,58 Risk factors in the early disaster aftermath include loss of personal and financial resources, loss of social support, dis- placement, loss of home, and proliferation of secondary stressors. Also at increased risk for psychiatric outcomes following disas- ters are persons living in poverty, low visibility groups (homeless, migrant, impaired mobility, institutionalized), and persons with trauma, psychiatric, or illicit substance use history. The goal is to deliver a compendium of pragmatically oriented interventions as soon as possible for individuals experiencing acute stress reac- tions or who appear unable to regain function.56,58 In general, interventions are designed to aid adaptive coping and restore problem-solving capabilities as quickly as possible. During the 1980s and early 1990s, critical incident stress debriefing surged in popularity and was widely adopted by disaster response per- sonnel. During this period, critical incident stress debriefing was applied (albeit, indiscriminately) with increasing frequency to disaster survivors; however, the technique was found to have equivocal effects and in some applications, to have the potential to cause harm.56–58

Psychological First Aid Psychological first aid (PFA) is emerging to capture essen-

tial components (core constructs) of empirically supported early disaster mental health interventions, ranging from meet- ing basic needs to more sophisticated interventions requiring

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an appropriately trained mental health professional. In some cases, either PFA or “Psychosocial Support” is being used, some- times interchangeably, as what appear to be social marketing catch phrases by disaster and humanitarian relief organizations (e.g., American Red Cross, World Health Organization) and U.S.-based trauma specialists (National Center for Posttraumatic Stress Disorder/Department of Veterans Affairs). The specific products and services delivered vary by the training and experi- ence of the provider, the context of the disaster setting (e.g., mass casualty vs. displaced into a shelter by a severe weather event), and the population being served (e.g., children, responders). Although each of these interventions cites empirical evidence as the basis for application, applied research is critically needed to determine intervention effectiveness and efficacy in realistic settings and the national and international planning scenarios.

Given the advent of the September 11, 2001 U.S. terror attacks, the anthrax bioterrorism acts, and a prolonged event with serial sniper attacks (Washington, DC metropolitan area), a core group of international traumatic stress and disaster experts was commissioned to amplify and expand the review of evidence and seek essential intervention elements to apply in the context of scenarios with ongoing threats.59 This process yielded five empirically supported intervention principles for application at the early to mid-term stages of such scenarios. These elements are especially relevant to pandemic influenza planners to aid in communications and community mitigation strategies.31 The goal is to move impacted populations along the following domain pathways59

■ From Risk to Safety ■ From Fear to Calming ■ From Loss to Connectedness ■ From Helplessness to Efficacy ■ From Despair to Hopefulness

One PFA model undergoing continuous development and refine- ment incorporated these and other empirically supported inter- vention principles into a manual and toolkit, which were first released as the devastating Hurricane Katrina impacted the Gulf Coast of the U.S.60 This resource is designed for delivery by men- tal health professionals and other disaster response workers who provide early assistance to affected children, families, and adults as part of an organized disaster response effort.

The American Red Cross has also revised their disaster men- tal health training curriculum and developed PFA strategies for use by all of their disaster relief workers. This includes use of a triage tag to link disaster clients with a Red Cross disaster men- tal health worker that would improve referral efficiency in mass casualty events (S. Hamilton, personal communication, January 10, 2007). Another emerging PFA model specifically targets the needs of children, parents, and their systems of care. It has been highlighted on the U.S. Department of Homeland Security web- site.61 In this model, parents and teachers are taught the basics of PFA to assist children by using the ideas of “listen, protect and connect.” New extensions of this model have been developed for schools and medical care settings.62

At the population level, effective psychological benefits may accrue in a systemic manner such as bridging primary care and mental health systems together and improving access to the broad range of human service needs (including housing, employment, schooling, and child care – to name a few). Such approaches, although not direct mental health interventions by mental health

providers, may be the most effective manner to provide PFA and improve coping.

BEHAVIORAL PREPAREDNESS FOR DISASTER RESPONDERS

The finding that resilience is common and expectable, even in the face of severe adversity, has been described as “ordinary magic.”48,63 Resilience is not a fixed attribute; instead, resilience is a process and it changes with changing disaster circumstances and experiences. The disaster experience may be transformative, enabling more constructive ways of dealing with adversity and stress.64 In this application, responder resilience refers to the capacity to adjust rapidly to the stresses of deployment, to suc- cessfully respond to adverse cultural and situational challenges, and to reintegrate to routine work in a healthy and adaptive fashion.

Responder Resilience

Focusing on resilience within the workforce makes good business sense for disaster response agencies.65 Responding optimally to mass trauma and mass casualty incidents requires a culture that prioritizes both physical health and psychological well-being for those who are called on to respond to incidents ranging in mag- nitude from crisis to catastrophe. Psychological preparedness improves disaster response. Enhancing resilience skills in the workforce will diminish the likelihood that 1) critical infrastruc- ture personnel (e.g., healthcare workers) refuse to work during a disaster – a major concern for an influenza pandemic;31 2) workers would quit, requiring massive retraining and rehabili- tation (a crippling reality following SARS in Toronto); and 3) loss of productivity, thus dampening the economy in a poten- tially cascading fashion. In the face of all-hazard planning and the need to maintain critical infrastructure and key resources, responder health, safety, and resilience must be integrated into organizational culture for public safety, health, and security.66

Hazards and risks to responders may be directly related to the reason for the deployment (e.g., infectious disease outbreak) or incidental to the deployment (endemic diseases, lack of medical facilities, and physical security hazards). Proper identification of hazards, assessment of the risks presented by these hazards, and appropriate control measures can, in most cases, reduce exposure to hazards and the consequent risks associated with the hazards that are present. Emergency response personnel are often required to work extended hours in high-risk environ- ments, where alertness and attention to detail are an absolute requirement for safe work practices. Elevated stress and fatigue can lead to faulty decision making, unsafe work behaviors, and increased exposures to health hazards.67

Organizational policy can prevent or mitigate injuries and illnesses from environmental, occupational, and operational threats including biological, psychological, and traumatic stress. Effective deployment health and safety policy requires coordina- tion and cooperation with appropriate occupational safety and health authorities to ensure continual refinement and implemen- tation of effective worksite health and safety plans.66 These plans need to be professionally designed and tailored to specific work- site conditions to protect deployed personnel by using a hierar- chy of exposure controls (engineering technology, administrative policies, and judicious use of personal protective equipment)

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and safe work practices. A comprehensive policy would cover predeployment preparation, deployment support, and postde- ployment services based on the best available information and protective measures. Before deployment, personnel must have completed all the elements to achieve a state of readiness. These include a medical determination of fitness for deployment, training on safe work practices, use of appropriate personal pro- tective ensembles, self-care (psychological, social, and behavioral dimensions), and other specialized training as needed to ful- fill job-related responsibilities. Pre-deployment briefings should provide information about anticipated exposure hazards, includ- ing psychological, social, and behavioral hazards from response activities and occupational stress factors (e.g., pace of work, mag- nitude of demands, and safety climate). Planning for continuity of operations and interoperable mutual aid (for demand surge) are also essential organizational preparedness responsibilities, as demonstrated by the devastating loss of the New York Fire Department Command Center in the September 11, 2001 World Trade Center collapse, and preparedness efforts for pandemic influenza.

Optimally, the responder has emergency plans and systems in place to handle concerns about the safety and welfare of family and other loved ones to avoid fractured attention on the job and increased likelihood for accidents, improper work practices, or poor decision making. Employers can assist with “concierge” ser- vices for families that are directly impacted.68 Healthy lifestyles (good nutrition, exercise, and sleep habits) and constructive social, spiritual, and family support are important to overall psy- chological well-being and resilience. Training and maintenance programs can be instituted for peer support, team building, and crisis leadership, with skill-building to improve stress, anger, and grief management.31

RECOMMENDATIONS FOR FURTHER RESEARCH

A number of key areas within disaster mental and behavioral health require research attention. Quantifying the psychological, behavioral, and social consequences and management strate- gies for disasters and mass violence is critical. Future efforts are needed to

■ Test emerging rapid mental and behavioral health assessment tools for population-based, facility-based, and clinical con- tact surveys, including assessment for mass casualty settings.

■ Integrate psychological and behavioral elements into population-based surveillance systems.

■ Implement an interoperable disaster mental health incident management strategy using evidence-based triage metrics and a continuum of stepped care.

■ Better understand the longitudinal trajectory of risk and impairment to improve interventions for persons with trau- matic grief during disasters and mass casualty events.

■ Identify and refine modifiable risk factors to help design effective intervention programs.

Despite the knowledge that early intervention mitigates risk for extended traumatic stress syndromes, the field has been hampered by misapplication and misrepresentation of early intervention strategies. Applied research is needed to identify useful early interventions (i.e., prove their efficacy) for those

directly impacted by disasters and mass violence. Such studies need to include

■ Research to establish international best practices for a con- tinuum of care through intervention strategies (i.e., PFA, incident-specific stress inoculation, and trauma-focused cognitive–behavioral therapy)

■ Determination of optimal timing of strategies to implement interventions

■ Component analysis of multifactorial interventions ■ Training and proficiency requirements for successful imple-

mentation of interventions (mental health and nonmental health professionals)

Research is also needed to evaluate the impact of efforts to increase preparedness and adherence to public health emergency response strategies including incident-specific disaster response strategies, such as sheltering and evacuation. More research and program evaluation efforts are needed to understand the key ingredients of resilience of professionals performing emergency response, disaster recovery, and remediation work. Naturalistic longitudinal studies would enable better anticipation of psy- chological and behavioral hazards for future preparedness and response planning. Furthermore, research is needed to evalu- ate the effectiveness of organizational approaches to enhancing resilience among response professionals and other personnel who are mandated to serve during disasters.

CONCLUSION

Planning for the behavioral and mental health needs of disaster- exposed individuals, families, communities, and responders is a critical need in public health and medical service planning. With- out such planning, the available resources, monitoring efforts, and healthcare services may be overwhelmed. Although “panic” is ill-defined and not often a concern, anxiety, fear for one’s children, and the absence of feeling safe can create community confusion and disillusionment with leadership that has substan- tial political consequences. Planning must address the range of responses from distress to risky behaviors to traditional mental illness. Unexpected service burdens may arise within receiving communities due to the migration of endemic risk and existing chronic conditions from displaced populations, in addition to newly emergent and chronic conditions aggravated by the disas- ter and relocation experience. Triage, protection from secondary stressors, restoration of families and social networks, and the application of the principles of PFA are the primary population- level interventions for the behavioral and mental health con- sequences of disaster and mass violence. Public messaging and leadership presence are critical to convey and implement these principles. At appropriate times, grief counseling – an important task in advancing communities to recovery – becomes the focus of all community leaders. First responders are always a target for planned mental and behavioral health support and surveillance to ensure their individual health status and, by doing so, com- munity protection. Addressing our knowledge gaps, applying sci- entifically supported interventions, and tracking the trajectory of unresolved needs are important objectives. Using leadership, public messaging, and education will greatly improve the mental and behavioral health of communities impacted by disasters and mass violence.

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