Mental health needs in emergencies

Six months after the tragic earthquake in Haiti, Dr Anna Datta and Justin Frewen examine the complexities of dealing with mental health problems following natural disasters and humanitarian emergencies

The horrific earthquake in Haiti earlier this year captured the headlines of the world’s media. Images of people being rescued from the rubble, accounts of personal tragedies, the calamitous damage inflicted upon the already impoverished country’s infrastructure and the difficulties involved in providing the required aid and assistance were all widely covered.
One area that received relatively less attention, however, was the mental ‘aftershock’ provoked by the disaster.
In addition to rebuilding the country’s infrastructure and providing essential services such as clean water, effective sanitation facilities, nutrition and shelter for the survivors, meeting the affected population’s mental health needs is also a matter of urgency.
Even as the traces of the physical damage inflicted upon the country disappears, many people are left internally scarred by serious mental health problems due to their traumatic experiences.
It is not surprising therefore that mental health issues are increasingly recognised as a crucial public health concern in such emergency situations, both in the immediate aftermath and over the longer term.
Acute and post-emergency support
The impact, gravity and duration of mental health problems faced by survivors depends on a number of factors. These include the extent and nature of the disaster; pre-existing mental health problems and prior traumatic experiences; the loss of relatives, friends or personal property; serious physical injuries suffered; and the presence or absence of family and community support.
As Dr Gerald Cohen, director of clinical affairs for the Division of Mental Hygiene in New York explains, disasters affect all of us, but in different ways. For some, the reaction may be mild, whereas for others it may be far more severe.
While certain people experience an immediate reaction, the mental health effects might lie dormant for weeks or months after the crisis.
The World Trade Center Registry revealed that approximately 25 per cent of survey respondents directly exposed to 9/11 recorded ‘post traumatic stress symptoms’ between two and six years after the attack. These longer-term reactions are a critical concern.
Consequently, separate intervention strategies need to be developed and implemented for the acute emergency — the immediate aftermath of the disaster or crisis — and post-emergency phases.
During the acute phase, the majority of mental health issues such as severe stress can be handled without resorting to medication. Mental health support generally consists of providing psychological first aid (PFA), involving noninvasive emotional support, preventing further harm or injury treatment of basic needs and arranging social support and networks. When feasible, these services should be organised and provided in the community.
Social interventions should continue during the post-emergency phase and mental health care will still be based on and delivered through the general healthcare system. Capacity building support should be provided for healthcare personnel through supervision and on-the-job training support. Community workers can be trained to provide outreach services and assist primary care personnel in the administration of heavy caseloads.
Assistance should also be provided in reducing the number of custodial mental health institutions, bolstering community and family care of persons with chronic mental health problems, and ensuring care is accessible in general healthcare settings.
Integrated mental health support
The provision of a holistic and integrated mental health support programme of activities and its incorporation into the overall relief effort, particularly in the area of general health, is crucial. The temptation to provide ‘stand-alone’ services that tackle one particular mental health concern or category (rape victims, amputees, bereaved family members) should be avoided. Such an approach risks creating a disjointed and uncoordinated system.
Whenever possible, mental health support should avail of currently existing and relevant local structures. By utilising available domestic structures such as the school system, community bodies, regional religious and political leaders together with the social, medical and mental health services, it will be possible to obtain increased access to the local population. This will help improve the sustainability of interventions and reduce potential ‘stigma’.
The integration of mental health into the primary care system is particularly important. This approach encompasses several benefits: firstly, local medical personnel and social workers can help greatly in tackling community mental health needs.
Secondly, they can help in the identification and treatment of patients with mental health issues.
Thirdly, the involvement of local primary care practitioners helps reduce ‘stigma’, as this can reduce the direct involvement of psychiatrist professionals; and fourthly, with a minimum of capacity-building support they will be able to take personal histories and identify any mental health issues that require further support.
Mental health of relief workers
In the cauldron of a complex emergency, the mental health of the first responders and humanitarian workers (rescue workers, relief experts, medical personnel and even journalists) are often neglected. Working long hours, frequently in precarious security conditions with inadequate management and organisational back-up, and surrounded by misery, death and destruction, relief personnel risk becoming emotionally and mentally drained.
Experience has shown that the most vulnerable humanitarian personnel are those who have been engaged in several successive assignments or who are on their initial deployment. Local staff have been identified as being especially at risk.
Policies and strategies need to be put in place to ensure the effective provision of mental health protection, and treatment if necessary, for front-line personnel in emergencies.
Basic psychological support, such as PFA, should be available to personnel who have directly experienced or observed potentially traumatic incidents.
In cases where their performance is seriously impaired or a risk to themselves or others, humanitarian workers should be relieved of their duties and provided with immediate support by a mental health professional.
Need for further research
Currently, there is a lack of reliable scientific evidence as to how best to provide culturally sensitive and appropriate mental health service support in complex emergencies. As a result, there is a growing demand for research to be carried out to ascertain the optimal means of mental health support provision, as well as the potential obstacles that might be encountered in so doing.
However, opposition to such research has come from various quarters on the grounds that funds spent in research are essentially resources that have been diverted from making additional support available for mental health service users. Moreover, concern has been voiced that the scientific community may exploit disaster survivors, who are already often extremely vulnerable.
In order to address such concerns, the Harvard Humanitarian Action Summit convened a Working Group on Mental Health and Psychosocial Support in Crisis and Conflict. This body examined the ethical dilemmas mental health researchers encounter and then produced guidelines and recommendations based on the Inter-Agency Standing Committee Guidelines on Mental Health and Psychosocial Support in Humanitarian Settings.
A central tenet of its report is that there should be “no survey without service” and “no service without survey”. In other words, there needs to be a dual commitment in mental health interventions and research. This will ensure that mental health support provided will directly benefit the intended ‘beneficiaries’ while at the same time contributing to future knowledge and best practices by generating research and evaluation findings based on implementation practice and activities.
It is anticipated that this approach to mental health research in emergency situations will help develop more equitable and effective systems of mental health intervention.
l Dr Anna Datta is an NCHD in Psychiatry at Mayo General Hospital and is following an International Masters in Mental Health Policy and Services (New University of Lisbon/WHO).
l Justin Frewen has worked for the UN since 1997 in Asia, the Middle East, Africa and the US and is following a PhD in Political Science at the University of Galway.