Addressing the mental health impacts of disasters and crises

Terminology

Throughout this document the term ‘disasters’ is used. This term is used to refer to specific large-scale traumatic events that are acute, whether seen or unforeseen, and have an immediate impact on people’s health and can have long term effects on individuals and communities. These can be natural disasters such as adverse weather events, bushfires etc as well as acute and ongoing crises such as pandemics, economic recessions, shooting crises, war torn issues or acts of terrorism. For specific details about the effects of climate change and climate driven events please see Position Statement 106: Mental health impacts of climate change.

Background

Disasters, including those linked to climate change, can lead to a wide range of deleterious health effects. This includes mental health conditions and mental disorders, health risk behaviours and effects on other social and behavioural domains, health perceptions and physical health.[1]

Some communities and groups are at higher risk or have unique mental health needs following traumatic incidents such as people in rural, regional and remote areas, First Nations people, culturally and linguistically diverse (CALD) communities, children and adolescents and people with pre-existing health conditions.[2] First Nations people with close emotional and ancestral ties to the land are also likely to be disproportionately affected by environmental change and extreme weather events.[3] People who have pre-existing psychiatric morbidity when a disaster occurs are at greater risk and may need to be closely monitored.[1] Health care provided following disasters and crises must be trauma-informed and culturally safe – see Position Statement 100: Trauma-informed practice and Position Statement 105: Cultural safety.

The impacts on mental health by traumatic effects does varies depending on the individual and the nature of the disaster. In the aftermath of natural disasters, such as adverse weather events and bushfires, evidence shows an increase in the rate of anxiety, depression and post-traumatic stress disorder in affected individuals and communities.[4] Similarly, rates of mental ill-health and presentations of psychological stress have been observed to increase during pandemics, most recently during COVID-19.[5] Recessions have also been observed to have similar effects, often exacerbated by the impacts on the social determinants of health such as wealth, employment and housing. [6] The impacts are particularly felt by younger generations as effects on hope and loneliness can produce psychological scarring.[7] Although the mental health effects of disasters do present and manifest in different ways, traumatic events have an undeniable and observable effect on mental health regardless of their exact nature.[1] 

It is important that disaster and crises response acknowledges and accommodates for the long-term effects on mental and physical health. The long-term impacts on mental health should be accommodated for in critical and emergency responses to disasters and crises. These accommodations should take into account the longitudinal effects on mental health,[8] and the ongoing social determinants that will continue to affect communities.[9]

As such, mental health must be a key consideration when formulating planning and responses to such events, and when developing strategies for recovery. The Australian Government is currently implementing the National Disaster Mental Health and Wellbeing Framework to integrate mental health into disaster planning and preparation, and the Aotearoa New Zealand Government has the National Health Emergency Plan.

Role of the psychiatrist

Prevention and resilience building

Preventative health planning is crucial for effective disaster response, including mental health supports and public health principles.[10] During times of stability, psychiatrists should work with other services in effective planning and preparation so that best practice systems and responses are ready to be rolled out following an event. They can participate in providing training and education to mental health, medical and other health professionals involved in providing services and clinical responses in order to increase the likelihood of evidence-based effective interventions being provided for those adversely affected. 

Psychiatrists can also take leadership roles in public health discussions regarding the impact of traumatic events such as disasters and their effects on individual and community mental health. As noted in Position Statement 106: Mental health impacts of climate change mental health institutions, practice and activities have a role in reducing carbon emissions and enhancing sustainability to mitigate the mental health impacts of climate change. Psychiatrists, as part of the wider community, may also have a role in early intervention for certain crises such as lone-actor grievance fuelled violence through risk assessment and early identification.[11, 12]

Psychiatrists and other mental health professionals should also undertake research into strategies for resilience building, prevention and effective treatments for people who have been traumatised. Evidence shows that even after those effected have ‘recovered’ from the initial impacts of a disaster, ongoing effects can emerge and relapse rates can remain high.[13] Increasing coping skills and development of support mechanisms to assist in building resilient individuals and communities are important ways in which psychiatrists can mitigate the effects and after effects of disasters.[14]

Psychiatrists should also ensure that preventative and resilience building measures are appropriate for specific populations. Culturally safe care and approaches are crucial. First Nations knowledge can be integrated into resilience building programs where appropriate as these communities have recognised practices for mitigating the effects of certain disasters.[15]

Response to disasters and crises

In the aftermath of disasters and crises, psychiatrists can work in collaboration with other mental health professionals, emergency responders and recovery agencies, as leaders in service delivery and clinical care. Psychiatrists have a key clinical leadership role in providing treatment for people who develop mental health disorders following exposure to a traumatic event, as well as those with pre-existing mental health problems whose condition may have deteriorated.[16] 

However, many people who have been affected by disasters and crises will seek help from other sources before seeing a psychiatrist. Emergency services personnel, general practitioners, and disaster relief workers will be the frontline support for both physical and mental health support. GPs have been shown to provide the majority of self-sought health care immediately following critical incidents.[17] Up to a third of distressed people presenting at shelters and family assistance centres presented with adjustment disorders or conditions such as major depression and substance abuse.[18] Psychological first aid is a crucial aspect of disaster response and should be a part of preparedness plans and training for responses to disasters. Psychiatrists have a role to play after these initial interventions are provided, and referral and triage processes should accommodate for this fact. 

Consultation-liaison and community-based psychiatric services engaging with the injured population are essential at this stage.[19] People with physical illness or injuries may present with an increased risk of mental health comorbidities, and consultation-liaison psychiatrists should be present to assess this. Consultation-liaison and community-based work should extend to general advice for community leaders, as well as to emergency services organisations.[16, 20]

Psychiatrists should also be present to provide expert mental health advice and support to other groups, such as general practitioners and counsellors, following a disaster and crises.[16] Research shows that common post-disaster mental health morbidities such as post-traumatic stress disorder tend to be under-recognised and that referrals to mental health specialists by generalist medical practitioners tend to be much lower than the rate of mental health complications in affected populations.[21]

Where distress persists and symptoms emerge in the weeks following the traumatic event, psychiatrists can be amongst the health professionals who provide simple psychological strategies that promote recovery and allow early detection of more serious problems. A small but significant number of people exposed to these traumatic events develop clinical disorders and severe distress.[1]

Psychiatrists and other mental health clinicians will then provide evidence-based psychological and pharmacological treatments. In these cases, psychiatrists would normally work with others dealing with physical health, welfare, and accommodation, work and school systems to ensure a coordinated approach.[16] Provision of mental health supports after disasters and crises is a longitudinal process and involves direct service provision as well as supporting and engaging with community services, frontline healthcare, other mental health specialists, and lived experience groups.

Digital technologies and telehealth services have the capacity to supplement traditional methods of service provision when responding to disasters and crises. The expansion or telehealth services played a key role in ensuring continuation of care and access to services during the COVID-19 pandemic.[22] It is important, however, that these services be provided and monitored in line with best practice principles – see Position Statement 98: Benefits of e-mental health treatments and interventions and Professional Practice Guideline 19: Telehealth in psychiatry. 

Supporting rural and remote communities

The impacts of natural disasters can be further devastating for people in rural and remote settings. Geographical barriers can lead to significant delays in the arrival of rescue and response teams, prolonging trauma in these communities, delaying the availability of mental health support, and exacerbating emotional distress.[23] This is especially the case when the accessibility of necessities such as shelter, clean water, medication, power and food are also affected.

Extended exposure to traumatic circumstances combined with delayed access to mental health services, information and resources can increase risk of mortality and morbidity immediately following the event, resulting in higher levels of social and emotional wellbeing problems, and a heightened risk of mental illness in the longer term.[24]

Additionally, psychiatrists, other health workers, carers and whānau may themselves struggle with lack of access to information and resources prior to, in anticipation of and following disasters and crises.[25] This can limit the capacity of this group to deliver support, impacting on the sustainability of these vital roles and leading to burnout.[25]

Communities, including traditional Māori and Aboriginal and Torres Strait Islander institutions, play a crucial role in providing support, reassurance and solutions to problems faced as a result of loss, destruction and disconnection from home and country.[26] In New Zealand these include the Pa, Marae, Hapū and Iwi. In Australia, the RANZCP recommends consultation and liaison early on with local Aboriginal and Torres Strait Islander elders to identify relevant community groups and leaders. It is vital that professional services work closely with grassroots representatives to ensure culturally appropriate and meaningful psychosocial recovery.[27]

Psychiatrists as consumers

It is important to note the impact of disasters and providing mental health services during or after crises can impact the mental health of clinicians. Those clinicians caught up in the events of a disaster can experience the same potential health impacts of the traumatic experience. However, there is the added risk of vicarious trauma associated with providing relief and support services to people seeking help.[28]

Terms such as burnout, moral injury, and moral distress have been used to describe distress in clinicians.[29] Workloads, time pressure, stressful environments, long working hours, poor resources, poor teamwork, a sense of lacking control, and incidences of discrimination, bullying and harassment are factors that contribute to burnout and adverse psychological outcomes.[30, 31] The nature of providing services during and post disasters will exacerbate many of these stressors for psychiatrists.

It is important for psychiatrists to be aware of the risks for themselves and their colleagues when providing mental health services during and after disasters. To mitigate the risks involved trauma-informed approaches towards the workforce are required at individual, organisational, and systemic levels when responding to disasters. Efforts to integrate a trauma-informed approach can include individual reflection, supportive supervision, positive, professional peer and mentoring relationships, and ensuring the maintenance of work-life balance as much as practicable, even during crises.[32]

Provisions should be made to address such issues systematically through occupational mental health and safety programs.[25] In providing support to response workers, individually tailored approaches are considered best practice. These should occur within the context of an understanding that the care and management of psychological trauma is not just a matter for the short term and requires a long-term view and follow up.[25]

For more information about mitigating the risks to psychiatrist during crises response see Position Statement 48: Safety and wellbeing of psychiatrists and those in psychiatry training.

Recommendations

To ensure that the best quality evidence-informed mental health care is provided during and in response to disasters, the College recommends that:

• Mental health be a key consideration in planning and modelling the responses to disasters.
• Culturally safe and trauma-informed care be provided during and after disasters in both immediate and long-term formats.
• Health workforce funding and training must be increased to acknowledge the immediate and ongoing impacts of climate change and disasters.
• Ongoing support and wellbeing services for psychiatrists and all other disaster response workers be prioritised in planning for disaster responses.
• Priority populations such as Aboriginal and Torres Strait Islander people, culturally and linguistically diverse groups, rural, regional and remote communities and people with existing mental health conditions must be a priority in resilience and prevention resourcing.
• Governments and organisations empower psychiatrists to contribute to evidence-based research on the impacts of acute disasters and crises on mental health.

References

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3. Affairs UNDoEaS. State of the World’s Indigenous People. Division for Social Policy and Development. Secretariat of the Permanent Forum on Indigenous Issues; 2010.
4. Eva Gifford and Robert Gifford. The largely unacknowledged impact of climate change on mental health. Bulletin of the Atomic Scientists. 2016;72:1-6.
5. Australian Institute of Health and Wellbeing. Mental Health impact of COVID-19. Canberra: Australian Institute of Health and Wellbeing; 2021.
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Disclaimer 

This information is intended to provide a general guide to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances or information or material that may have become subsequently available.