Disaster Psychiatry: Readiness, Evaluation, and Treatment

Disaster psychiatry has a long history as a field of intervention and an emerging area of science and clinical care. In the past two decades, it has become a well-defined area of clinical care and research. In 1992 the APA established the Committee on Psychiatric Aspects of Disaster. As a clinical specialty, disaster psychiatry includes care for the individual and populations and requires skills that range from the stethoscope to development of communitywide interventions (1). The care models are built on clinical skills, knowledge of communities, knowledge of culture, and the ability to work across disciplines. Drs. Stoddard, Pandya, and Katz have made a major contribution to the clinical textbooks of care in their well-developed and clinically focused Disaster Psychiatry.

The book is structured in three major parts. The first is focused on readiness, the second on evaluation, and the third on intervention. The volume also includes special topics and a valuable appendix of additional readings and resources. The structure highlights the importance of offering a range of care, to serve the individual as well as the community. The volume has multiple outstanding contributors; each chapter serves as a stand-alone clinical guide to preparedness, assessment, treatment, and population-level interventions. Much of the clinical wisdom will seem familiar to clinicians engaged in the care of patients exposed to trauma and disaster. The compilation of this knowledge with public health intervention strategies and information about public health structures and roles is a unique contribution.

The volume opens with a description of the incident command structure, which is very important to those who respond to disasters yet is not well known by most physicians. It is the operating structure for delivering care and responding in most emergency settings. Similarly, how to communicate about risk during disasters is a population intervention important to keeping communities informed about available resources, decreasing inappropriate health care seeking, and educating about appropriate needs for care. Each of the chapters is followed by review questions, which form an excellent resource for evaluating one's own knowledge or developing an evaluation program for a residency track or fellowship track that includes disaster and trauma care. Disaster Psychiatry wisely includes a chapter on self-care in disaster response. Those who work with trauma victims know the cost of sustaining work in an emergency setting for days, weeks, and months while working with people who are injured, physically as well as mentally, and supporting the entire medical care team. The symptoms of compassion fatigue are an important focus for caring for oneself as well as for intervention with one's medical colleagues during times of disaster.

The first task of disaster mental health care is a needs assessment to determine resource allocation for the delivery of care. The volume thoroughly describes this task and explains its key importance to forming the disaster mental health care team. Usually mental health care is not what is needed in the first 24–48 hours, during which life-sustaining operations are most urgent. However, assessing during this time the needs that will soon be required and collaborating with the medical care team in order to be able to support their work and develop modes of communication are critical processes.

An often forgotten component of disaster response is care for those with serious mental illness. A full chapter is devoted to this topic and covers it well. In times of disaster, persons with chronic illnesses of all kinds lose access to care, lose their caring community (physicians, nurses, and health care providers), and lose their medications and other treatment interventions. Whether those are antipsychotic medications, antianxiety medications, oxygen, or renal dialysis, the impact of loss of care is an important focus for ensuring health and well-being in disaster-stricken populations. Similarly, the book highlights issues of substance abuse, including data documenting that substance use increases after exposure to trauma and disaster, although the data on the new development of substance abuse after such events are less compelling. Increased substance use is a risk not only to the individual but also in workplaces and on the highway, where vehicular accidents can be a major outcome of psychiatric distress. The management of medical complaints and the role of triage are also discussed.

After the impact phase of the disaster, as recovery from the disaster becomes the focus, the management of grief and resilience are primary. Our science of understanding the grief response, effective interventions for pathological grief, and the role of community and culture in recovery from grief are emerging. The chapter on this topic provides vital information for both individual and community recovery.

Psychological first-aid concepts have emerged from an expert consensus panel and are the organizing principles of early intervention in disaster communities (2). The principles of safety, calming, connectedness, self-efficacy, and hope organize the interventions for psychological first aid. Now conceptualized in several forms, the core concepts remain the same (3). These principles are informed by evidence, but further research is needed. The psychotherapies and psychopharmacology for posttraumatic stress disorder (4), anxiety disorders, depression, and substance abuse are well described and summarized. Alternative interventions also receive attention, including meditation and yoga, which are often found to be helpful and calming after disaster exposure. In addition, the volume addresses the special needs of the elder population. Because older persons frequently have chronic medical illnesses and decreased mobility, community interventions for preparation as well as early response need special consideration.

In disaster care, psychiatrists have unique roles in providing not only individual care but also population health care and in making resource decisions. Consultations to community leaders—from pastors, ministers, and rabbis to mayors, teachers, and other key community figures—can provide much needed information to inform decisions on individual community care. When psychiatry enters the disaster community, collaboration with primary care usually provides the best approach to mental health services and long-term recovery needs. Drs. Stoddard, Pandya, and Katz have made a substantial contribution to the dissemination of knowledge for disaster psychiatry. The volume will inform clinicians and provide essential training in residency programs and fellowships and in continuing medical education.