Disaster Psychiatry Outreach (DPO) is a 501c3 not-for-profit organization formed to provide Mental Health and Psychosocial Support (MHPSS) in the aftermath of disasters and terrorist events. DPO was formed in 1998 though the goodwill of psychiatrists responding to the Swissair 111 aviation disaster, filling a gap present in services offered by responding groups. We recognize that while MHPSS is gaining more recognition and research in recent years, the impact of neglected or improperly addressed mental health and psychosocial issues is massive. Research from many recent disasters shows that while most people are resilient and recover well without specific intervention, there is a significant burden of mental health and psychosocial issues which persist, often for years following an event.
Based on the literature and years of experience responding to multiple disasters, we expect that while most Nepalese will recover well without specific intervention, and in fact may grow stronger as a result of overcoming adversity, a significant subset of the population, and a larger subset of first responders (e.g. military, police, medical personnel, rescue workers, etc.) may experience a greater burden of mental health and psychosocial issues. These same groups are less likely to receive the necessary attention, a situation which is gradually improving due to increased recognition of the unmet need, and changes in the culture of first responders, where seeking help or revealing “weakness” often is met with stigma and actual consequences (e.g. being removed from duty or transferred to office jobs).
In their recent review Mental Health Consequences of Disasters (Annual Review of Public Health, 2014), Goldman and Galea affirm that most people are resilient, and “experience distress for a short time period and quickly return to pre-disaster levels of functioning”. Nevertheless, a subset of affected persons develop pathological reactions which require treatment. Post Traumatic Stress Disorder (PTSD) ranges in literature reviews from 30-40% for direct victims, 10-20% among rescue workers, and 5-10% in the general population, varying depending on several factors including type of disaster, degree of exposure, and how research is conducted. Major Depressive Disorder (MDD) is common in the general population at baseline. MDD is significant post-disaster, ranging from 5-10% in the affected population.
Substance use (alcohol, cigarettes and other drugs) has also been show to increase after disasters, but is not as well studied. Disaster is thought to have the most significant impact on those who already have a problem with substances, especially if other symptoms are present. Other symptoms arise after disasters, including generalized anxiety, death anxiety, panic and phobias, as well as experiences such as grief, suicidal thinking, and maladaptive stress responses. Survivors of disasters also report somatic symptoms including sleep disruption, headache, fatigue, abdominal pain, and shortness of breath.
Reviews of mental health and psychosocial issues following earthquakes and other natural disasters affirm that while most people recover without specific interventions, doing very well with family and community support and the re-establishment of basic safety, a subset of the population will experience issues such as those noted above. In addition, people with pre-existing psychiatric conditions tend to do worse after a disaster, particularly in communities in which mental health services are scarce. Notably, first responders have a higher burden of PTSD, MDD and non-specific distress reactions. Unfortunately such responders are often reluctant to seek attention as noted above, due to stigma and the culture of first responders, lack of access to care, and inadequate education about warning signs and when to seek help.
Due to the massive damage and strain on or frank lack of resources in the initial weeks post-earthquake, as well as recurring aftershocks and delays in relief, we expect the MHPSS burden to be potentially significant in spite of Nepal’s rich and resilient culture and strong community. We also expect these factors of community cohesion to be powerful protective factors for many, but we do not want to fail to respond to those who are in need of additional support. Without intervention of the right sort, focused and specialized, affected Nepalese in the general population and among first responders are at risk for doing more poorly over time than they might otherwise do with proper attention.
DPO works respectfully of local culture and groups, seeking to respect customs and work to empower local communities, people and healthcare providers. We recognize that we are guests in another’s home, and that our stay will be limited in time. As such, we provide the following short-term services with the goal of leaving things better and more sustainable than when we arrived: 1) needs assessment – to help identify possible gaps in available resources, 2) targeted training and support for local providers, 3) basic services as applicable, 4) special attention to first responders, 5) intermittent missions at 3 and 6 months following the initial needs assessment to check on conditions and progress, 6) long-term support as needed to enable local providers to recognize and address issues common following disasters.
We especially attend to the needs of vulnerable populations such as children and families, particularly when there have been large displaced or refugee populations, effectively arranging “Kids Corners” which provide opportunities for play for child and family, community-building, and therapeutic evaluation in a normalizing setting. We follow the model we have instituted over more than 15 years of providing pro bono disaster psychiatric response, including in regions such as Sri Lanka following the 2004 tsunami, where we provided immediate services and support, and worked with a local group to establish a self-sustaining community complete with a peer support system, as professional assistance was not readily available in the region. We work flexibly with local providers, community leaders, and authorities to provide a responsive and sensitive marrying of local resources with our knowledge, experience and best-practices. Based on post-response assessments conducted in the past, our efforts have been effective and appreciated, while placing a minimal strain on resources required for basic needs due to our low operational overhead and practice of providing services through the goodwill of our volunteer (no cost for professional services is ever billed to DPO or passed on to the stakeholders). Support given to DPO goes directly to covering basic expenses and administrative support for current missions.
Goldman & Galea, Mental Health Consequences of Disasters (2014), Annu Rev Public Health. 2014;35:169-83. doi: 10.1146/annurev-publhealth-032013-182435. Epub 2013 Oct 25.