- By Dr Amit Choughule
Disaster is a very a broad term, which implies a diverse set of circumstances from an act of terrorism (manmade disaster) to natural calamities like earth quake. Disasters are known to have substantial effect on both physical and mental health of the affected population.
In 1992 the World Health Organisation’s (WHO) defined disaster as a severe disruption, ecological and psychosocial, which greatly exceeds the coping capacity of the affected community.
In 1995, Federal Emergency Management Agency of US have defined disaster as, ‘Any natural catastrophe, regardless of cause, any fire, flood, or explosion that causes damage of sufficient severity and magnitude to warrant assistance supplementing State, local, and disaster relief organization efforts to alleviate damage, loss, hardship, or suffering.
The Disaster Management Act 2005 of India disaster is defined as a catastrophe, mishap, calamity or grave occurrence in any area, arising from natural or manmade causes, or be accident or negligence which results in substantial loss of life or human suffering or damage to, and destruction of property, or damage to, or degradation of, environment, and is of such a nature or magnitude as to be beyond the coping capacity of the community of the affected area.
PRINCIPLE OF DISASTER MENTAL HEALTH:
Disaster mental health services are based on the principles of ‘preventive medicine’. This principle of ‘prevention’ has necessitated a paradigm shift from relief centered post-disaster management to a holistic, multi-dimensional integrated community approach. This has ignited the paradigm shift from curative to preventive aspects of disaster management. This can be understood on the basis of six ‘R’s such as:
- Readiness (Preparedness)
- Response (Immediate action)
- Relief (Sustained rescue work)
- Rehabilitation (Long term remedial measures using community resources)
- Recovery (Returning to normalcy)
- Resilience (Fostering)
DIFFERENT PHASES OF DISASTER MENTAL HEALTH:
Community’s and individual’s reactions to the disaster usually follow a predictable phase:
- Heroic phase:
Immediately after the disaster, survivors in the community usually show altruistic behaviour in the form of rescuing, sheltering, feeding, and supporting the fellow human beings. Hence this phase is called as heroic phase. This phase usually lasts from a day to weeks depending upon the severity, duration of exposure and availability of the relief sources from various agencies.
- Honeymoon phase:
Once the relief agencies step in, survivors are relocated to safer places like relief camps. Media attention, free medical aid, free food and shelter, VIP visits to the camp, administrations’ sympathy, compensation package, rehabilitation promises provides immense sense of relief and faith in survivors that their community will be restored in no time and their loss will be accounted through monetary benefits. Hence this phase is called honeymoon phase, which usually lasts for 2-4 weeks.
- Disillusionment phase:
At the end of 2-4 weeks, relief materials and resources start weaning. VIPs and politicians visit stops. Media coverage reduces. Administration, relief agencies and NGO’s involvement start fading. This brings the survivors to the ruthless world of post disaster life. The reality of complex process of rebuilding and rehabilitating appears a distant dream because of administration hurdles, bureaucratic red tapism, discrimination, injustice and corruption. This harsh reality of the disillusionment phase provides a fertile soil for breeding mental morbidity which lasts for 3-36 months before the community restores to harmony. The role of mental health workers is immense during this phase.
- Restoration phase
PREVALENCE OF MENTAL HEALTH MORBIDITY IN DISASTER AFFECTED POPULATION:
Prevalence of mental morbidity in disaster affected population varies from 8.6 to 57.3 percent
Mental health disorders noted during disasters can be classified into acute phase (1-3 months) and longterm phase (>3 months). Majority of the acute phase reactions and disorders are self-limiting, whereas longterm phase disorders require assistance from mental health professionals.
COMMON MENTAL DISORDERS SEEN IN THE DISASTER AFFECTED POPULATION:
Common disorders are: Adjustment disorders, depression, post traumatic stress disorder (PTSD), anxiety disorders, non-specific somatic symptoms and substance abuse. Researchers have assigned that the PTSD as the signature diagnosis among post disaster mental morbidity. Prevalence of PTSD reported in literature varies from 4-60%.
ROLE OF MENTAL HEALTH PROFESSIONALS IN DISASTER SITUATION:
- I. During pre-disaster period (preparedness)
- Public Education Activities – Life skills education, educating about the disaster mental health
- Disaster Response Network – to develop collaboration with various existing agencies like governmental agencies, NGO’s and community health workers
- Disaster response training of trainers in disaster mental health
- first aid training (both medical and psychological)
- counseling skills
- stress management
- identifying common mental disorders and referral
- life skills training
- Psycho education regarding mental health in trauma/disaster for the general population
- Community level support and community resilience training
- Strengthening Information, Education and Communication (IEC) activities
- Immediately after the disaster (heroic and honeymoon phases)
- Being part of the multi-disciplinary relief team
- Rapid assessment (mental health surveillance)
- magnitude of the psychological impact
- available mental health resources in the affected community
- social, cultural and religious perspective of the community
- Providing health care
- medical and psychological first aid
- the pre-existing mentally ill patients
- substance intoxication and withdrawal in survivors
- crisis intervention
- establishing the referral system
- Providing targeted disaster mental health interventions to the needy
- Disaster psychiatry outreach teams to provide care
- Promoting of resilience and coping
- Dealing with the victims and volunteers stress (stress management)
- Fostering the mass grieving / mourning
- Collaborating with administrative and funding agencies
- Mental health education – do’s and do not’s
- Educating the administrative personnel, local leaders and public
- Utilizing mass media to reach the survivors
- Initiating collaboration with the local agencies for capacity building and outside agencies for support
- Planning research
III. During disillusionment phase
- Providing care for the mental ill patients
- Attending to the referrals
- Continuing and expanding the capacity building activities
- Training of resourceful community members like private physicians/doctors, primary health care staff, paramedical staffs, school teachers, anganwadi
- workers, alternative complementary medicine personnel’s, religious leaders, spiritual leaders and faith healers
- Community outreach camps
- Hand holding of the community health workers
- Assessment of the interventions and feedback mechanism
The principal components of psychological first aid (Source for this table is modified and adapted from World Health Organization 2011
- Getting in touch with survivors
- Protection from further threat and distress
- Protecting survivors from unnecessary exposure to additional traumatic events and trauma reminders
- Immediate physical care
- Helping to locate family members
- Sharing the experience (but not forced)
- Normalization or Validation of the emotions
- Facilitating a sense of being in control
- Linking survivors with sources of support and resources
- Identifying those who need further help and referral
It is defined as group discussions that occur within 48-72 h after an event and are often referred to as ‘psychological de-briefings.
Sessions encourage participants to describe and share both factual and emotional aspects of their disaster experience. Principle behind this debriefing is that immediate processing gives an individual the ability to cognitively restructure the perceived disaster event so that it is remembered in a less traumatic way.
ROLE OF PSYCHOTROPIC MEDICATIONS IN DISASTER MANAGEMENT:
Generally use of psychotropic medications is discouraged in disaster management because of the popular notions like a) disaster reactions are generally normal people in abnormal situations and b) majority of the symptoms are self limiting.
Prophylactic uses of psychotropic medications in survivors are discouraged. There are no well controlled studies to say that prophylactic use of medicine decreases psychiatric morbidity.
use of prophylactic psychotropic medications may be justified in pre-existing mental illness to avoid relapse, in acute substance withdrawal to avoid complications, suicidal attempt and severe depression.
Suresh Bada Math, Maria Christine Nirmala, Sydney Moirangthem, Naveen C. Kumar. Disaster Management: Mental Health Perspective. Indian Journal of Psychological Medicine Jul – Sep 2015; Vol 37:Issue 3 261