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Mental Health Response to Community Disasters: A Systematic Review

Carol S. North, MD, MPE1,2; Betty Pfefferbaum, MD, JD3
[+] Author Affiliations
1VA North Texas Health Care System, Dallas
2Department of Psychiatry and Department of Surgery, Division of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
3Terrorism and Disaster Center, Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City
JAMA. 2013;310(5):507-518. doi:10.1001/jama.2013.107799.
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Importance  Exposure to a disaster is common, and one-third or more of individuals severely exposed may develop posttraumatic stress disorder or other disorders. A systematic approach to the delivery of timely and appropriate disaster mental health services may facilitate their integration into the emergency medical response.

Objective  To review and summarize the evidence for how best to identify individuals in need of disaster mental health services and triage them to appropriate care.

Evidence Review  Search of the peer-reviewed English-language literature on disaster mental health response in PsycINFO, PubMed, Cochrane Database of Systematic Reviews, Academic Search Complete, and Google Scholar (inception to September 2012) and PILOTS (inception to February 2013), using a combination of subject headings and text words (Disasters, Natural Disasters, Mental Health, Mental Health Programs, Public Health Services, Mental Disorders, Mental Health Services, Community Mental Health Services, Emergency Services Psychiatric, Emotional Trauma, Triage, and Response).

Findings  Unlike physical injuries, adverse mental health outcomes of disasters may not be apparent, and therefore a systematic approach to case identification and triage to appropriate interventions is required. Symptomatic individuals in postdisaster settings may experience new-onset disaster-related psychiatric disorders, exacerbations of preexisting psychopathology, and/or psychological distress. Descriptive disaster mental health studies have found that many (11%-38%) distressed individuals presenting for evaluation at shelters and family assistance centers have stress-related and adjustment disorders; bereavement, major depression, and substance use disorders were also observed, and up to 40% of distressed individuals had preexisting disorders. Individuals with more intense reactions to disaster stress were more likely to accept referral to mental health services than those with less intense reactions. Evidence-based treatments are available for patients with active psychiatric disorders, but psychosocial interventions such as psychological first aid, psychological debriefing, crisis counseling, and psychoeducation for individuals with distress have not been sufficiently evaluated to establish their benefit or harm in disaster settings.

Conclusion and Relevance  In postdisaster settings, a systematic framework of case identification, triage, and mental health interventions should be integrated into emergency medicine and trauma care responses.

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Figure.
Disaster Mental Health Case Identification, Triage, and Interventions

This diagram systematically directs disaster mental health responders through 3 components of psychiatric assessment, starting with identification of psychopathology and differentiating it from normative emotional distress, proceeding to triage to the appropriate type of care, and concluding with delivery of appropriately targeted interventions based on accurately assessed needs. Activities are shown in the general sequence in which they would occur and at the approximate time they would first occur; activities would continue beyond 6 weeks into the indefinite future, as indicated by the particular situation.aMeets Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) for postraumatic stress disorder (PTSD).bMajor depression, bereavement, anxiety.cScreening may be conducted as a first step to identify individuals unlikely to develop a psychiatric disorder, but full diagnostic assessment is needed before formal psychiatric decisions are made (2 weeks are required after disaster for diagnosis of new cases of major depression and 1 month for PTSD).dSuicidal or homicidal ideation, psychosis, psychiatrically based inability to care for self or dependents.

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