AWARD PAPER: DR VENKOBA RAO ORATION
Year : 2018 | Volume
: 34 | Issue : 1 | Page : 7--10
Mental health services in disaster-affected population in low-resource settings
Rakesh Kumar Chadda
Department of Psychiatry and National Drug Dependence Treatment Centre, All Institute of Medical Sciences, New Delhi, India
Prof. Rakesh Kumar Chadda
Department of Psychiatry and National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi - 110 029
The paper discusses planning mental health services in disaster-affected population in low-resource settings. Disasters, both natural and artificial, are not uncommon in the modern world. Mental health problems are common in a disaster-affected population. Disaster often traumatizes and devastates the affected population badly, also damaging the available resources. Planning mental health services include assessing the needs, accessibility of the area, available resources and their mobilization, and coordination with the local authorities and policymakers. Mental health professionals need to take a prompt initiative and leadership role. The author discusses his own experience in planning such a service in Kashmir in November 2005 following a massive earthquake which affected the state on October 8, 2005. Role of the National Disaster Management Authority of India in the management of disasters is also briefly discussed.
|How to cite this article:|
Chadda RK. Mental health services in disaster-affected population in low-resource settings.Indian J Soc Psychiatry 2018;34:7-10
|How to cite this URL:|
Chadda RK. Mental health services in disaster-affected population in low-resource settings. Indian J Soc Psychiatry [serial online] 2018 [cited 2022 Sep 25 ];34:7-10
Available from: https://www.indjsp.org/text.asp?2018/34/1/7/228787
Disasters can happen anywhere across the world, including in low-resource countries like India. Disasters are associated with massive loss to the human resources, including the loss of life and major injuries. About one-third or even more of individuals, exposed to disaster, may develop disorders such as anxiety, depression, acute stress disorder, adjustment disorder or posttraumatic stress disorder (PTSD). Thus, mental health services constitute an essential component of any disaster relief plan to avoid adverse mental health consequences of disaster.
Mental Health Consequences Of Disasters
Mental health consequences of disasters may not be as apparent as the physical injuries following the offending event. A systematic approach is required for case identification and developing appropriate interventions. Symptomatic individuals in post-disaster settings may experience new-onset disaster-related psychiatric disorders, exacerbations of preexisting psychopathology, and/or psychological distress. It is estimated that 11%–38% of the distressed individuals presenting for evaluation at shelters and family assistance centers in disaster-affected population have stress-related and adjustment disorders, bereavement, major depression, and substance use disorders. Around 40% of the distressed individuals have preexisting mental disorders. Persons with more severe reactions to the disaster stress are more likely to accept a referral to mental health services than those with less severe reactions.
Mental Health Services In Disaster -Affected Population In Low Resource Settings
Natural disasters include earthquakes, cyclones, avalanches, landslides floods, Tsunamis and droughts, whereas artificial disasters include nuclear, chemical and biological disasters, nuclear and radiological emergencies, and terrorist attacks and wars. Disasters such as floods, train accidents, bomb blasts, and insurgency activities are common in India. Any disaster needs mobilization of a large amount of resources, which may be difficult to arrange in low-resource settings.
As discussed, mental health problems are common in disaster-affected populations. Most of the population affected by a disaster is in a state of great stress and is in need of mental health services. Although immediate needs may consist of security, shelter, food, and other daily needs, mental health needs remain an important component of disaster service planning.
Planning mental health services for a disaster-affected population is a challenge, especially in low-resource settings. Planning includes need assessment, looking into the accessibility of the disaster area, available resources and their mobilization, liaison with the local community and other sectors involved in relief work, and provision of long-term care.
This paper discusses India as an example of low-resource setting. India is a vast country with the northern territory surrounded by snowy mountains and a large part of the eastern, western, and southern boundaries bordering the sea. A large part of the country lies in a high-risk zone for earthquakes. Natural disasters such as hurricanes and floods, as well as the artificial disasters such as train accidents and accidental fires are also common. Providing mental health services to a disaster-affected population remains a big challenge.
Experience Of Providing Services To A Disaster -Affected Population
On October 8, 2005, the state of Kashmir was affected by a massive earthquake. The epicenter of the earthquake was located at 34.6 N Latitude and 73.0 E Longitude, 40 km West of Muzaffarabad in Pakistan. Tremors were also felt in many Northern States of India, i.e., Jammu and Kashmir, Himachal Pradesh, Delhi, Uttar Pradesh, Rajasthan, Haryana, Punjab, and Uttarakhand. Damage was more severe in Pakistan occupied Kashmir and two districts of Kashmir, Baramulla and Kupwara. In the Indian Kashmir, 1195 civilians had lost their lives, whereas 4373 were seriously injured. Nearly one hundred and fifty security force personnel belonging to the Indian army, border security force, police, and the border road organization were also killed. Pakistan occupied Kashmir had faced much more severe damage with the number of casualties being nearly 100,000.
Geographically, the towns of Tangdar and Uri, and areas around had borne the brunt of tragedy. More than 50 villages were seriously damaged. Over 73,000 houses were damaged and 42,750 houses were completely destroyed. Some villages had all the houses damaged. The hospitals at Uri and Tangdar had been extensively damaged.
Constitution of disaster mental health team and its objectives
Following the disaster, the Government of India constituted a team of mental health professionals consisting of three psychiatrists, two clinical psychologists and four psychiatric social workers, drawn from the All India Institute of Medical Sciences, New Delhi and the Post Graduate Institute of Medical Education and Research, Chandigarh. The team was stationed in Kashmir from November 8 to 21, 2005.
Kashmir has a difficult and remote terrain. A number of agencies were involved in relief work, including the Indian army, local police, the Departments of Health, Governments of Kashmir and India, and other local resources. Objectives of our team included assessing the mental health needs of the earthquake-affected population, screening them for mental health problems, and providing treatment and psychosocial counseling to the persons distressed and diagnosed as having psychiatric problems, and to sensitize and impart training to the doctors and the paramedical professionals in management of disaster associated mental health problem.
Thus, broadly the work of team could be grouped under the clinical care and sensitization programs. There were two distinct pockets (Uri and Tangdar), which had shown more devastation. Thus, we divided our team into 3 groups: one group of 2 persons remained stationed in Srinagar, the state capital and two groups of 3–4 persons each went to Uri and Tangdar sectors, respectively.
Work by clinical teams
The teams stayed at the site and mapped the affected villages in their area taking help of the army. Each team would travel 4–5 h every day to reach the affected villages. Advance information of the visit would be sent to the village to be visited. Clinics were conducted in most of the affected villages. The teams covered >30 villages during the period and provided services to 450 patients.
The teams provided psychiatric assessment, medications, counseling, and psychoeducation to the persons having psychiatric disorders and psychosocial problems. There was also focus on strengthening the local workforce resources by sensitizing the local health personnel to the local emergent needs. The patients were advised to follow-up at local government dispensaries and were also advised that they could also meet the teams again at Uri and Tangdar Health Centre on the last day of the contact program.
All patients seen in the clinics had their houses destroyed by the earthquake. Nearly one-fourth had suffered serious physical injuries, and 12% had lost one of their family members. Common psychiatric diagnoses included adjustment disorders (39.6%), depressive episode (22.6%), and other stress disorders (21.8%). Only 10 (3.3%) patients were found to suffer from PTSD, though PTSD-like symptoms were reported by more than two-third of the patients. In a number of cases, the affected people had suffered stress-related symptoms immediately following the earthquake in the form of sleep disturbance, nightmares, and anxiety, which had settled down with support from the other survivors and the rescue teams.
The state of Jammu and Kashmir is very uniquely placed with respect to its socio-political situation. The local population has faced years of terrorism due to a political conflict leading to terrible loss of life and property. A constant sense of fear and apprehension has affected all aspects of their daily living. This conflict may have equipped these people with coping strategies which helped them to deal with and survive under such conditions. It is possible that the conflict enabled the local populace to adapt in a better or a different manner to natural or artificial disasters.
Two team members conducted a 1 day (two sessions of about 3 h) training program for doctors and paramedical professionals at the Regional Institute of Health and Family Welfare, Dhobiwan, Baramulla. The Institute was located about 25 km away from the city of Srinagar. The members would daily travel from Srinagar to the Institute and come back in the evening.
The purpose of the training programs was to sensitize the local health professionals to the mental health problems occurring in a disaster-affected population. Since the time was limited, the emphasis was on discussing the basic issues, so that they could provide satisfactory follow-up services to the patients who were seen by the teams, and to refer to the specialist, wherever required. The trainers also attended to some patients who would land at the Institute on hearing about the visit by a team there. The training program was carried out in two sessions of 90 min each for batches of 20–25 doctors and 30–40 paramedical professionals, respectively. A total of 160 doctors and 216 paramedical professionals attended the program.
It would have been preferable to make a preliminary assessment of the needs by drawing a representative sample of the affected population. However, it was not possible due to the vastness of the affected area and poor connectivity to the affected villages due to the difficult hilly terrain. More so, the timing was also critical since the peak winter was forthcoming and a lot of the local area would have become inaccessible due to snowfall, and the team had wanted to contact as much population as possible. It was not possible for the team to stay for a longer period due to logistic reasons. Thus, the team could provide services to an only limited number of persons. Only one consultation could be given and follow-up could not be done, though the patients seen were asked to continue follow-up at the local health services. It had not been possible to collaborate with the local mental health professionals during the team's visit.
It is possible to deliver basic mental health services to the disaster-affected population using a community-based model after basic needs of food and shelter have been secured by the rescue teams. The local health workers can be sensitized to the mental health needs of the disaster-affected population to help ensure continued care of the affected population.
Model For Developing Mental Health Services In A Disaster -Affected Population
A model for developing disaster mental health services first need to assess the nature and severity of the disaster and the extent of population affected, damage to life and physical injuries. One also needs to know the extent of damage to the local infrastructure and needs for food, shelter, and safety. Since there is also a possibility of damage to the road network, accessibility of the area affected also needs to be looked into. Then, one needs to assess the resources available including the local administrative infrastructure, general health and mental health structure and workforce, and community resources like welfare agencies.
Since the local infrastructure is also overburdened, a cautious approach is required with minimal expectations from the local resources. However, coordination is very important among various agencies, both external and local, for providing the relief work. It is important to mention here that the first and foremost basic need is of a safe and secure shelter, food and clothing, taking care of physical injuries, and the mental health needs come the next. A provision of continuity of care should always be taken care of after the relief teams go back to their respective places. This is true for mental health services also.
The mental health team needs to integrate with the existing health and mental resources, and provide necessary inputs to strengthen the local infrastructure, who have to take care of the long-term needs. Services would include taking care of immediate mental health issues such as stress and grief reactions, anxiety and depression, and also assistance to the local resources for long-term care. The modern information technologies such as mobile phones, SMS, WhatsApp, and E-mail can be utilized for information sharing and providing supportive services. The visiting team can also keep a provision of periodic follow-up after few months.
Role Of National Disaster Management Authority Of India
National Disaster Management Authority (NDMA) of India has given explicit guidelines for psychosocial support and mental health services, which include psychosocial first aid, integration with general relief work, integration with the health plan, referral to specialist services, linkages with local nongovernmental organizations, integration with community practices, continuity during recovery, and rehabilitation and reconstruction phases. Specific guidelines have been provided for the vulnerable groups such as women, children, and the elderly. Similarly, there is also a provision of guidelines for the care providers, who are also facing a lot of stress in their role of providing care to the disaster victims. Further details can be accessed at the NDMA site.
Mental health professionals need to take initiative and leadership role in the provision of mental health services in a disaster-affected population. Any service planning would include need assessment, looking into the accessibility to the place of the event, mobilizing all resources available, developing linkages with the local agencies and looking into both the immediate and long-term requirements. It is possible to provide services by linking with the available resources even in low-resource settings.
The author would like to thank the other members of the Mental Health Team (Prof Anil Malhotra, Dr N Kaw, Dr Jaspreet Singh, Braham Prakash, Deepak Yadav, Davinder Rana, Pritpal Singh and Om Prakash Giri), which provided the services, Director Health Services, Kashmir, Regional Institute of Health and Family Welfare, and the Ministry of Health and Family Welfare, Government of India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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