ROUND TABLE
Mental and social health during and after acute emergencies: emerging consensus?
Santé mentale et sociale pendant et après les situations d'urgence aiguë : émergence d'un consensus ?
La salud mental y social durante y después de las emergencias agudas: ¿principio de consenso?
Mark van OmmerenI,1; Shekhar SaxenaII; Benedetto SaracenoIII
ITechnical Officer, Mental Health Evidence and Research, Department of Mental Health and Substance Abuse, World Health Organization, 1211 Geneva 27, Switzerland
IICoordinator, Mental Health Evidence and Research, Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
IIIDirector, Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
ABSTRACT
Mental health care programmes during and after acute emergencies in resource-poor countries have been considered controversial. There is no agreement on the public health value of the post-traumatic stress disorder concept and no agreement on the appropriateness of vertical (separate) trauma-focused services. A range of social and mental health intervention strategies and principles seem, however, to have the broad support of expert opinion. Despite continuing debate, there is emerging agreement on what entails good public health practice in respect of mental health. In terms of early interventions, this agreement is exemplified by the recent inclusion of a "mental and social aspects of health" standard in the Sphere handbook's revision on minimal standards in disaster response. This affirmation of emerging agreement is important and should give clear messages to health planners.
Keywords: Stress disorders, Post-traumatic/psychology/therapy; Mental health services/organization and administration; Social adjustment; Adaptation, Psychological; Emergency services, Psychiatric; Trauma centers (source MeSH, NLM).
RÉSUMÉ
Les programmes visant à dispenser des soins de santé mentale pendant et après les situations d'urgence aiguë dans les pays à faibles revenus sont considérés comme d'un intérêt discutable. Aucun accord n'a été trouvé sur la valeur en termes de santé publique du concept de trouble de stress post-traumatique et sur l'utilité de services verticaux (séparés) dont l'activité est axée sur les traumatismes. Il semble cependant qu'une série de stratégies d'intervention en santé sociale et mentale bénéficie d'un large soutien parmi les experts. Bien que les débats se poursuivent, un accord se fait jour sur ce que comportent les bonnes pratiques de santé publique en matière de santé mentale. En ce qui concerne les interventions précoces, cet accord est illustré par l'introduction récente d'une norme sur les aspects mentaux et sociaux de la santé dans la révision du Manuel Sphère sur les normes minimales à respecter dans la réponse à un désastre. Cette affirmation d'un accord émergeant est importante et devrait se traduire par des messages clairs pour les planificateurs dans le domaine de la santé.
Mots clés: Etat stress, Post-traumatique/psychologie/thérapeutique; Service santé mentale/organisation et administration; Adaptation sociale; Adaptation psychologique; Service urgences psychiatriques; Service traumatologie (source: MeSH, INSERM).
RESUMEN
Los programas de atención de salud mental durante y después de las emergencias agudas en los países con recursos escasos han sido objeto de polémica. No hay ningún acuerdo sobre el valor del concepto de trastorno de estrés postraumático en el terreno de la salud pública, ni lo hay tampoco acerca de la idoneidad de los servicios verticales (independientes) centrados en los traumas. Sin embargo, hay varias estrategias y principios de intervención en la salud social y mental que parecen gozar de un amplio respaldo entre los expertos. Aunque prosiguen los debates, se observa un principio de acuerdo sobre lo que definiría las prácticas más adecuadas de salud pública en el campo de la salud mental. En lo referente a las intervenciones precoces, ese consenso se ve ilustrado por la reciente inclusión de una norma sobre los «aspectos mentales y sociales de la salud» en la revisión de Sphere handbook sobre las normas mínimas de respuesta ante desastres. Esta confirmación de un principio de acuerdo es importante y debe traducirse en mensajes claros para los planificadores de la salud.
Palabras clave: Estrés postraumático/psicología/terapia; Servicios de salud mental/organización y administración; Ajuste social; Adaptación psicológica; Servicios de urgencia psiquiátrica; Centros traumatológicos (fuente: DeCS, BIREME).
Recent literature records a discussion about the concepts, values and appropriateness of mental health interventions to reduce the burden of war and other disasters in resource-poor countries (19). The post-traumatic stress disorder (PTSD) construct and trauma-focused services are the focus of controversy. Results from epidemiological studies suggest that this disorder is prevalent (10) and, at least in the USA, disabling (11). A vocal group of observers, however, sees PTSD as a pseudocondition with no relevant burden especially in non-western, traditional societies (1, 6, 8). While these critics point to medicalization of normal distress and the possible harm of assuming that western models of illness and healing are valid across cultures, others consider denial of the importance of traumatic stress a professional error and a denial of preventable suffering (2, 3, 5).
Trauma-focused interventions are increasingly provided to large segments of populations affected by disaster in resource-poor countries. However, the interventions that are most often implemented to reduce traumatic stress one-off psychological debriefing (organized by international and local organizations) and benzodiazepine medication (prescribed by local physicians) have little evidence of effectiveness, and their indiscriminate application can be harmful (1214). Following disasters in resource-poor countries, foreign clinicians often arrive to promote PTSD case-finding and trauma-focused treatment (6) in the absence of a system-wide public health approach that considers pre-existing human and community resources, social interventions, and care for people with pre-existing mental disorders.
The controversy is compounded by the recent development of a new field introduced by international organizations working in low-income countries that calls itself psychosocial. The term is used to indicate commitment to non-medical approaches and distance from the field of mental health, which is seen as too controlled by physicians and too closely associated with the ills of an overly biopsychiatric approach. Yet, despite highly appropriate attention to medicalization and the importance of non-medical intervention, separating psychosocial care services from mental health care services may inadvertently promote exclusively biological care for the severely mentally ill by drawing human resources skilled in non-biological interventions away from formal mental health services (15). This separation further divides a care system that is already fragmented.
Because of the expression of these viewpoints, the impression may have been created that programme planners are faced with choosing between setting-up vertical (separate) trauma mental health programmes, setting-up vertical psychosocial care programmes outside existing systems, or ignoring mental health care altogether. Indeed, early editions of the highly influential Sphere Project's minimum standards for disaster response (16, 17) did not cover mental health because of perceived expert disagreement (Nan Buzzard, verbal communication, October 2002).
In order to generate sound advice on strategies to assist countries, we commissioned a literature review and a postal survey of expert opinion, involving responses by experts to open-ended questions about mental health policy in the aftermath of disasters (18). In addition, we studied available consensus statements and guidelines (W1922, 2328), many of them published by experienced international organizations. The overall picture that emerged is that, although opinions vary widely on the public health value of focusing on PTSD and trauma services, there is agreement on basic issues: exposure to extreme stressors is a risk factor for social and mental health problems, including common mental disorders; further, emergencies can severely disrupt social structures and ongoing formal and informal care of persons with pre-existing disorders. A range of strategies seem to have wide support of much expert opinion, on the condition that they are tailored to the local context, needs and resources.
On the basis of our study of the above-mentioned survey, consensus statements and guidelines, we have proposed principles and strategies for populations exposed to extreme stressors (29). The eight principles are: contingency planning before the acute emergency, assessment before intervention, use of a long-term development perspective, collaboration with other agencies, provision of treatment in primary health care settings, access to services for all, training and supervision, and monitoring indicators (see Table 1).
Distinct intervention strategies should be considered for the acute emergency and post-emergency phases, and these will be discussed separately. Also, we aim to achieve a conceptual distinction between social and mental health interventions. The term social intervention is used for interventions that aim primarily to have social effects, and the term mental health intervention for those that aim primarily to have mental health effects. It is acknowledged that social interventions tend to have secondary mental health effects and the converse. Social interventions are typically not in the domain of expertise of mental health professionals. As such interventions tend to deal with important factors influencing mental health, however, health and mental health professionals should work in close partnership with colleagues from other disciplines (e.g., communication, education, community development, and disaster coordination) to ensure that relevant social interventions are fully implemented.
Many of the strategies described here may be common sense, but by making them explicit in documents and policy statements they become a powerful tool for programme planning and evaluation. These principles and strategies have been developed for resource-poor countries where the vast majority of disasters arise but they are also considered appropriate for high-income countries. In high-income countries additional strategies also apply, involving, for example, cognitive-behaviour therapy (30) by clinicians with advanced training, who are a rare resource in poor countries (31).
Acute emergency phase
For the purpose of this paper, the acute emergency phase is defined as the period where the crude mortality rate is elevated because of disaster-induced deprived physical needs (such as food, shelter, physical security, water and sanitation), access to health care, and management of communicable diseases. A key early social intervention concerns information: a reliable flow of credible information must be ensured about the emergency, efforts to establish physical safety, relief efforts (including what each aid organization is doing and where it is located), and the location of relatives. Access to valid information is a basic right and is essential to reduce public anxiety and distress. Information should be uncomplicated, so as to be comprehensible at the cognitive level of local 12-year-olds, and empathic, showing understanding of the situation of the survivors.
Two other core social strategies are likely to reduce public stress: encouraging normal activities and encouraging active participation in the community. For example, re-establishing cultural and religious events is seen as helpful. Such events typically include funeral ceremonies and grieving rituals involving spiritual and religious practitioners. For children, restarting formal or informal schooling is considered important, together with the provision of some recreational activities. Health professionals should be active advocates for safe, physical space for all these activities. In terms of achieving participation, adults and adolescents need to be encouraged to engage in tangible, purposeful activities of common interest, such as relief efforts. Community activities that facilitate the inclusion in social networks of people without families are strongly recommended.
With respect to mental health interventions, The world health report 2001 recommends making mental health treatment available within primary and other health-care settings, which requires staff training, supervision, and a referral system (32, 33). This recommendation tends to apply whether primary health care is run by government or by nongovernmental organizations, because integrated care within primary and other health facilities maximizes access to mental health care. Health officials need to ensure the availability of essential psychotropic medications for urgent psychiatric problems, for example psychoses and severe depression. During the acute emergency, most persons with urgent psychiatric complaints will have pre-existing disorders, which may have been exacerbated by suddenly discontinued psychotropic medication. We have outlined elsewhere essential strategies to address ongoing care and protection of people in custodial psychiatric hospitals during acute emergencies (34).
Some people will immediately seek help at health services because of mental health problems directly related to their exposure to extreme stressors. According to a recent consensus-building exercise (26), most acute stress problems during acute emergencies are best managed without medication following the principles of psychological first aid, which involves non-intrusive emotional support, coverage of basic needs, protection from further harm, and organization of social support and networks. When community workers are available, outreach and psychological first aid may be organized in the community. Nevertheless, the weight of current evidence discourages the blanket use of isolated sessions of psychological debriefing that push people to share their personal experiences beyond the extent to which their natural inclination would prompt them to do so (12, 14).
The strategies outlined here may be adapted for use in acute emergencies caused by unpredictable infectious diseases, along the lines of the WHO document on public mental health aspects of biological and chemical weapons (35).
Post-emergency phase
The acute emergency phase is followed by a post-emergency phase when the crude mortality rate is again at a level comparable to that before the acute emergency or, in the case of displacement, at the level of the surrounding population. In complex disasters typically with coexisting conflict, population displacement, food scarcity, and the collapse of basic health services (36) the sequence of events is less linear, and different areas of a country may oscillate between acute and post-emergency phases.
In the post-emergency phase, the social interventions outlined above should continue. Moreover, whenever disaster-inflicted poverty becomes an evident ongoing source of suffering, it is appropriate for health workers to advocate economic re-development initiatives, such as microcredit schemes or income-generating activities.
During this phase, general health care should continue to form the basis of the mental health care system. Accordingly, mental health specialists should provide thorough supervision and on-the-job training to health-care staff (33). Community workers may be trained and supervised to assist primary care staff with heavy case-loads (33) and to conduct outreach activities. The development of a multitude of specialized trauma-focused services should be avoided unless mental health care is available in general health care and other community settings (the school health system, for example). Trauma-focused care may be best integrated into general mental health services.
Organizing community-based self-help support groups is likely to provide a valuable form of assistance (25). The focus of such groups is usually problem-sharing, brainstorming for solutions or for more effective ways of coping (including traditional ways of coping), and generation of mutual emotional support, and sometimes promotion of community-level initiatives. In certain contexts, collaboration with traditional resources such as faith healers may be an opportunity in terms of care, provision of meaning, and generation of community support.
These post-emergency strategies need to be carried out in synergy with ongoing mental health system development priorities, especially the development of national plans for the organization of mental health services (37), which is increasingly a focus of work by WHO. Executing such plans involves downsizing existing custodial mental hospitals, making mental health care available in general health care settings (4), and strengthening community and family care of persons with chronic, severe mental disorders (32, 37).
Conclusion
This paper began with a summary of the debate on the controversial value of PTSD and trauma-focused care during and after acute emergencies. This debate has attracted much attention and has been valuable in bringing to light fundamental issues and various views with respect to the needs of trauma survivors. We acknowledge that there is no agreement on the public health value of the PTSD concept (e.g., the extent to which non-comorbid PTSD is associated with disability), and the appropriateness of vertical trauma-focused services. We share the concern of Silove et al. (7) that because of heated expressions of opinions an impression has been created that programme planners during and after acute emergencies are faced with a choice between specialized, trauma-focused care or completely ignoring mental health. We advocate the implementation of social interventions and the integration of trauma-focused care into general mental health care, which should be available in general health care settings.
Despite ongoing debate, we argue that there is considerable agreement on what entails good public mental health practice. Most of our proposed early intervention strategies have now been included in a "mental and social aspects of health" standard in the health chapter of the recently revised Sphere handbook on minimum standards in disaster response (38). It is the first time that this widely used handbook written to improve humanitarian assistance and enhance accountability includes a standard covering mental and social health. Because of frequent war and other disasters in many regions of the world, this affirmation of emerging consensus is important and gives clear messages to health planners. 
Acknowledgements
Dr Alistair Ager, Dr Thom Bornemann, Dr Joop de Jong, Dr Alessandro Loretti, Dr Srinivasa Murthy, Dr Bhava Poudyal, Dr Beverly Raphael, Dr Derrick Silove and Dr Robert Ursano reviewed an early draft of the described principles and strategies and provided substantial comments. We are grateful to the Governments of Finland and Italy for financial support of the work leading to this publication.
Conflicts of interest: none declared.
References
1. Bracken PJ, Giller JE, Summerfield D. Psychological responses to war and atrocity: the limitations of current concepts. Social Science and Medicine 1995;40:1073-82.
2. de Vries F. To make a drama out of trauma is fully justified. Lancet 1998;351:1579-80.
3. Dyregrov A, Gupta L, Gjestad R, Raundalen M. Is the culture always right? Traumatology 2002;8:1-10.
4. Jones L, Rustemi A, Shahini M, Uka A. Mental health services for war-affected children: report of a survey in Kosovo. British Journal of Psychiatry 2003;183:540-6.
5. Mezey G, Robbins I. Usefulness and validity of post-traumatic stress disorder as a psychiatric category. BMJ 2001;323:561-3.
6. Pupavac V. Therapeutic governance: psycho-social intervention and trauma risk management. Disasters 2001;25:358-72.
7. Silove D, Ekblad S, Mollica R. The rights of the severely mentally ill in post-conflict societies. Lancet 2000;355:1548-9.
8. Summerfield D. Bosnia and Herzegovina and Croatia: the medicalization of the experience of war. Lancet 1999;354:771.
9. Wessely S. War and the mind: Psychopathology or suffering? PalestineIsrael Journal of Politics, Economics and Culture 2003;10:6-16.
10. de Jong JT, Komproe IH, van Ommeren M. Common mental disorders in postconflict settings. Lancet 2003;361:2128-30.
11. Kessler RC. Posttraumatic stress disorder: the burden to the individual and to society. Journal of Clinical Psychiatry 2000;61 Suppl 5:4-12.
12. Ballenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Marshall RD, Nemeroff CB, et al. Consensus statement update on posttraumatic stress disorder from the International Consensus Group on Depression and Anxiety. Journal of Clinical Psychiatry 2004;65 Suppl 1:55-62.
13. Freeman C. Drugs and physical treatment after trauma. In: Ørner R, Schnyder U, editors. Reconstructing early intervention after trauma. Oxford: Oxford University Press; 2003:169-76.
14. Rose S; Bisson J; Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database Systematic Reviews 2002;2:CD000560.
15. Saraceno B. Mental health: scarce resources need new paradigms. World Psychiatry 2004;3:3-6.
16. Humanitarian charter and minimum standards in disaster response. Geneva: Sphere Project; 1998.
17. Humanitarian charter and minimum standards in disaster response. Geneva: Sphere Project; 2000.
18. Weiss M, Saraceno B, Saxena S, van Ommeren M. Mental health in the aftermath of disasters: consensus and controversy. Journal of Nervous and Mental Disease 2003;191:611-5.
19. Psychosocial effects of complex emergencies: symposium report. Washington (DC): American Red Cross; 1999.
20. Utrecht guidelines: draft guidelines for the evaluation and care of victims of trauma and violence. Geneva: United Nations High Commissioner for Refugees; 1993. Available from: http://www.hprt-cambridge.org/Layer3.asp?page_id=23
21. Declaration of cooperation: mental health of refugees, displaced and other populations affected by conflict and post-conflict situations. Geneva: World Health Organization; 1999.
22. Mollica RF. Kikuchi Y. Tokyo guidelines for trauma and reconstruction: formulating new principles and practices for the recovery of post-conflict societies. Available from: http://www.hprt-cambridge.org/Layer3.asp?page_id=22
23. Guidelines for programmes psychosocial and mental health care assistance in (post) disaster and conflict areas: draft. Utrecht: Netherlands Institute for Care and Welfare; 2001. Available from: http://websrv1.nizw.nl/nizwic/_Werkdocs/Publications/guidelines.htm
24. Psychological support: best practices from Red Cross and Red Crescent programmes. Geneva: International Federation of Red Cross and Red Crescent Societies; 2001.
25. de Jong JTVM. Public mental health, traumatic stress and human rights violations in low-income countries. In: de Jong JTVM, editor. Trauma, war, and violence: public mental health in socio-cultural context. New York (NY): Plenum; 2002:1-93.
26. National Institute of Mental Health. Mental health and mass violence: evidence-based early psychological interventions for victims/survivors of mass violence. A workshop to reach consensus on best practices. Washington (DC): US Government Printing Office; 2002. NIH Publication No. 02-5138. Available from: http://www.nimh.nih.gov/research/massviolence.pdf
27. Weine S, Danieli Y, Silove D, van Ommeren M, Fairbank JA, Saul J, for the Task Force on International Trauma Training of the International Society for Traumatic Stress Studies. Guidelines for international training in mental health and psychosocial interventions for trauma exposed populations in clinical and community settings. Psychiatry 2002:65;156-64.
28. Psychosocial and mental well-being of migrants. Geneva: International Organization for Migration; 2002. 99th Session of Executive Committee.
29. Mental health in emergencies: psychological and social aspects of health of populations exposed to extreme stressors. Geneva: World Health Organization; 2003. Available from: http://www.who.int/mental_health/media/en/640.pdf
30. Shepherd JP, Bisson JI. Towards integrated health care: a model for assault victims. British Journal of Psychiatry 2004;184:3-4.
31. Atlas: mental health resources in the world. Geneva: World Health Organization; 2001. Available from: http://www.who.int/mental_health/media/en/244.pdf
32. The world health report 2001 Mental health: new understanding, new hope. Geneva: World Health Organization; 2001. Available from: http://www.who.int/whr2001/2001/main/en/pdf/whr2001.en.pdf
33. de Jong K, Ford N, Kleber R. Mental health care for refugees from Kosovo: the experience of Medicins Sans Frontières. Lancet 1999;353:1616-7.
34. van Ommeren M, Saxena S, Loretti A, Saraceno B. Ensuring care for patients in custodial psychiatric hospitals in emergencies. Lancet 2003;362:574.
35. Mental health of populations exposed to biological and chemical weapons. Geneva: World Health Organization; 2005. Available from: http://www.who.int/mental_health/prevention/mnhemergencies/en/
36. Toole MJ, Waldman RJ. Refugees and displaced persons. War, hunger, and public health. JAMA 1993;270:600-5.
37. Organization of services for mental health. Geneva: World Health Organization; 2003. Available from: http://www.who.int/mental_health/resources/en/Organization.pdf
38. Humanitarian charter and minimum standards in disaster response. Geneva: Sphere Project; 2004. Available from: http://www.sphereproject.org/handbook/index.htm
1 Correspondence should be sent to this author (email: vanommerenm@who.int).