Rapid Assessments of Mental Health Needs After Disasters

The rapid needs assessments undertaken among adults and children 8 weeks after the December 2004 tsunami in Thailand and the results of these assessments reported in this issue of JAMA by van Griensven and colleagues¹ and by Thienkrua and colleagues² mark an impressive advance in the field of psychiatric epidemiology. Strengths of these investigations include the timeliness of the studies, the prominent role played by Thai researchers, the application of rigorous sampling methods, and the inclusion of international and culture-specific indices of distress. In addition, 9-month follow-up data are provided, a rare achievement in disaster research undertaken in the developing world. These studies demonstrate both the feasibility and value of undertaking rapid needs assessments to guide mental health planning after disasters.

Yet critics continue to question if and how psychological trauma affects the mental health of disaster-affected populations, challenging the validity of the key diagnostic category of posttraumatic stress disorder (PTSD), particularly when applied across cultures.^{3 - 4} Screening for PTSD among survivors of disasters in developing countries, especially in acute situations, has faced a number of common criticisms, including the following: psychological trauma is a western concept that may be unfamiliar to other cultures⁴ ; PTSD has limited diagnostic validity because culturally diverse communities do not have equivalent terms for the constellation or for the individual symptom domains of the disorder; measuring traumatic stress across societies can yield misleading results, since the meaning of “symptoms” may differ across cultures; disaster-affected communities may not identify psychological stress as a priority need, as they may be more concerned with practical and social needs; a diagnosis of PTSD may encourage a culture of “victimhood” and passivity, potentially inhibiting communities from adopting an active approach to recovery⁵ ; traumatic stress “symptoms” may be normative coping mechanisms and do not necessarily lead to disability or impairment⁵ ; an emphasis on PTSD may encourage an individual and clinical focus, creating unrealistic expectations that all survivors should receive counseling; there is limited evidence that treatments for PTSD developed and tested in the West are effective across cultures and importing techniques from the West may undermine traditional healing mechanisms⁵ ; attention to social, material, economic, cultural, and human rights issues may be more important in facilitating natural recovery at a group level; and the emphasis on PTSD may obscure other pressing mental health needs.

Debate on the issue is widespread, with some experts emphasizing the importance of treating PTSD after disasters and others highlighting more pressing mental health priorities.⁴ The ongoing controversy risks confusing funding agencies and other donors, as well as those responsible for planning mental health programs as part of humanitarian relief efforts following disasters.

The Thailand-based studies by van Griensven et al¹ and Thienkrua et al² add to a growing body of research indicating that PTSD symptoms can be identified both in adults and in children across cultures. The key question, however, is whether the prevalence of PTSD symptoms in the immediate aftermath of disasters offers valid information and reliable direction to guide local mental health planning.

The study of adult tsunami survivors by van Griensven et al¹ yielded prevalence estimates for PTSD symptoms ranging from 7% to 12% at 8 weeks after the tsunami, with higher rates of symptoms of anxiety and depression. If these values are extrapolated to the wider tsunami-affected region, the numbers with PTSD symptoms would run into the several millions. If it is assumed that all these persons were disabled and in need of urgent mental health care, existing psychiatric services would clearly not have the capacity to meet the demand.

An important question, therefore, is how these high rates of trauma-related mental symptoms occurring soon after the disaster should be interpreted. In both Thai studies, the psychiatric indices were defined solely by the endorsement of symptoms, a method that might inflate prevalence rates unless psychosocial impairment is measured concurrently.⁶ For example, in Thailand, a fisherman who has intrusive memories typical of PTSD may still be able to take his boat out to sea, raising questions of whether he warrants urgent mental health attention. Early symptoms of depression and anxiety, even if severe, may reflect transient, reality-based experiences of grief, distress, and uncertainty about the future. Moreover, the meanings ascribed to particular experiences may vary across cultures. For example, seeing ghosts after catastrophes, as reported by some of the adult tsunami survivors—an experience that might be interpreted as a feature of PTSD—may reflect a mechanism of coping with memories of lost relatives.

A critical question is whether survivors with early symptoms of PTSD, depression, and anxiety warrant psychological interventions, particularly the nonspecific counseling that commonly is offered in these settings.⁴ Studies in Western settings have shown that generic forms of counseling are ineffective in reducing early PTSD symptoms.⁷ It may be that, more than receiving counseling, what most survivors need to facilitate natural recovery from trauma exposure and the resulting stress is the restoration of conditions of safety and predictability.⁵ Stabilizing the social environment and creating opportunities for survivors to resume their livelihoods and take control of their lives may be the best “therapy” for the community as a whole.⁵ In that respect, it is noteworthy that the Thai study of adults¹ found that loss of livelihood was an independent predictor of ongoing mental health problems. It seems plausible, therefore, that the program of rebuilding fishing boats in Thailand initiated soon after the tsunami may emerge as one of the best “mental health interventions” that encouraged psychosocial recovery.

Acute distress after major disasters is common and expectable. Importantly, however, the Thai studies^{1 - 2} showed that the rates of symptoms of PTSD, anxiety, and depression in adults decreased by approximately one half after 9 months. Children, on the other hand, showed little change in symptoms, raising questions of whether they continued to experience emotional isolation or grief following the loss of parents, an issue not measured in the studies. The difficulty facing the field is in predicting at baseline which subgroup of survivors will regain emotional stability over time if the social recovery environment is supportive and which will develop chronic, disabling symptoms requiring psychiatric interventions. The data available from the present investigations do not allow examination of this vital issue.

A related issue not addressed in the studies by van Griensven et al¹ and by Thienkrua et al² is whether respondents with symptoms of PTSD, anxiety, or depression perceived themselves to be ill, particularly soon after the disaster. In the West, a majority of persons with nonpsychotic disorders such as PTSD do not seek treatment,⁸ a pattern that is likely to be similar or more accentuated in Asian countries. An important issue is whether many survivors gain adequate support from informal social structures such as the family and religious leaders or whether the low utilization reflects a lack of awareness of, or poor access to, appropriate services.

How swiftly mental health systems can respond to the needs identified by rapid assessments remains a critical issue. Thailand has relatively advanced mental health services compared with some of its Indian Ocean neighbors. Moreover, in other regions severely affected by the tsunami, such as the north of Sri Lanka, the infrastructure for mental health already was undermined by years of civil war.⁹ In those settings, leaders in mental health have raised concerns about the uncoordinated posttsunami influx of international agencies offering untested, short-term treatments for traumatic stress.⁹ Building mental health systems in developing countries affected by disasters, whether human-instigated or ecological, is a slow and incremental process.¹⁰ Where international professionals offer assistance, time must be spent building partnerships with local professional counterparts, consultation is essential in planning and developing new and culturally sensitive programs, and initiatives must be integrated into local systems of care so that service developments are sustainable. In that respect, although needs assessments can be undertaken rapidly, in many developing countries, mental health interventions cannot be delivered with the same speed as can, for example, mobile emergency trauma surgery. It is imperative that a long-term perspective be adopted,¹⁰ with the process of skills transfer occurring in a manner that can be absorbed and implemented by local services.

Key areas of research that may help to address important concerns confronting the disaster mental health field include the following: recording indigenous concepts and terms for describing stress responses and comparing these with international indices for identifying mental health needs; including assessments of a wider range of stress reactions such as complicated grief, separation anxiety, somatoform disorders, anger, hatred and feelings of revenge, impulse-control disorders, and drug and alcohol abuse; identifying more accurately the personal, social, and cultural factors that encourage natural recovery from immediate stress reactions and those that predict chronicity and disability; including assessments of the needs of those with severe neuropsychiatric disorders such as psychosis and epilepsy; adding more precise measures of immediate survival risk (eg, suicidality, risk to others, and inability to cope with daily demands) and family burden associated with various manifestations of mental distress; establishing and including more measures of community strengths (eg, resilience, resourcefulness, cohesiveness, and social capital); including biological as well as social and psychological indices in the search for predictors of outcome for PTSD and related disorders; conducting longer-term follow-up assessments over years after a disaster to determine the trajectory of recovery; developing models of psychological intervention that identify and integrate the most useful elements from traditional and Western approaches; undertaking rigorous intervention studies, ideally drawing participants from baseline epidemiologic samples; and ensuring that investigations are ethically sound and have a strong capacity-building component, fostering the research of local investigators.

An important focus for future research is to include a wider range of categories of psychological reactions in addition to PTSD, anxiety, and depression, as was done in the studies among survivors of the tsunami.^{1 - 2} Complex disasters have diverse impacts on the community beyond life-threatening issues.⁵ Loss of family and social networks results in widespread grief that can become complicated and disabling in a minority of survivors,¹¹ possibly contributing to the poor outcomes in the children studied in Thailand. Although attention to grieving rituals and remembrance ceremonies can limit these adverse outcomes, some individuals may need specific grief therapy. Anger as a reaction to loss and trauma exposure is a common response that can be compounded by communal grievances that recovery needs are not being met in a timely manner.⁵ Attention to social, material, and economic needs is vital to promoting a sense of trust in the system of care.¹² Loss of roles (as parent, worker, provider, community leader, etc) and the attendant threat to the sense of identity⁵ are invariable, and, as the Thai studies show, the loss of livelihood in particular is a critical factor in maintaining high levels of PTSD, anxiety, and depression in survivors. Unless economic and social reconstruction efforts are effective, survivors may feel helpless, frustrated, and desperate. In addition, systems that confer existential meaning (eg, religion, spirituality, social cohesion, culture)⁵ are pivotal to the process of recovery in that they promote a sense of faith, hope, and social reintegration. Future research will benefit from examining more closely the extent to which the reestablishment of these broad social functions hastens individual and communal recovery from traumatic stress reactions.

There is limited evidence supporting the effectiveness of direct psychological interventions for common emotional disorders in the developing world. However, 2 studies, both undertaken in Uganda, suggest that specific interventions based on interpersonal and cognitive behavioral methods adapted from Western approaches can be effective in treating PTSD and depression across cultures.^{13 - 14} These initiatives offer promising pointers to future research. The most important next frontier for disaster mental health research is to evaluate which interventions (social, traditional, clinical) match the needs of different subgroups of survivors in diverse cultural contexts and how these needs—and matching interventions—may change as time passes after the disaster. Having mastered rapid needs assessments, researchers now must make full use of that platform to test interventions that make a difference.