APA-IPS: Disaster psychiatry – Nepal, Ebola, and beyond

NEW YORK – After the earthquake in Nepal earlier this year, Disaster Psychiatry Outreach sent in volunteers who found preexisting issues that made their mental health response challenging at best, Dr. Ram Suresh Mahato reported at the American Psychiatric Association’s Institute on Psychiatric Services.

Nepal was recovering from armed conflict that lasted from 1996 to 2006 and resulted in what some have called a “postconflict identity crisis” (Int J Educ Dev. 2014;34:42-50). The caste system in the country was abolished in 1963, but social inequality continued to persist. In addition, more than 60 languages are spoken in Nepal, and at least 25% of the population lives below the poverty line, said Dr. Mahato, a Disaster Psychiatry Outreach (DPO) volunteer who was part of the needs-assessment team dispatched to the country in May.

Dr. Sander Koyfman

Other complicating factors included high rates of domestic violence. Nepali women are at greater risk of depression, anxiety, and posttraumatic stress than are males (Lancet. 2008 May;371[9625]:1664) and (J Affect Disord. 2007 Sep;102[1-3]:219-25), and a culture of silence prevails, Dr. Mahato said. The literature describes informal social networks in Nepal in which community members share their distress and symptoms, “as well as traditional (shamanistic) healing practices for those suffering mental health complaints in relation to political violence” (Soc Sci Med. 2010 Jan;70[1]:35-44).

Dr. Mahato spoke at a workshop, sponsored by DPO, aimed at urging psychiatrists to be prepared in providing mental health services to disaster survivors across the globe and here at home. “The room was full last year,” said Dr. Sander Koyfman, DPO’s president, referring to the intense interest in Ebola at the height of the outbreak in 2014. “This year, it’s more of a challenge, as interest wanes from disaster to disaster,” but their organization would like to “sustain the desire in mental health providers and disaster responders to learn how to help most effectively,” Dr. Koyfman said in an interview.

The presentation focused on the mental health aspects of the Ebola response and the more recent DPO work following the earthquake in Nepal that killed 10,000 people. In a striking similarity, about 10,900 people died in the wake of the Ebola epidemic in West Africa and its rolling impact across many regions. (In May, the World Health Organization declared Liberia free of Ebola but said on Oct. 14 that a preliminary study published in the New England Journal of Medicine shows that the virus can persist in the semen of some survivors for at least 9 months.)

Vulnerable suffer most

Over the last 10 years, more than 1.4 million people have been injured and about 23 million have been left homeless across the globe because of man-made and natural disasters, according to a 2015 United Nations report. “Overall, more than 1.5 billion people have been affected by disasters in various ways, with women, children, and people in vulnerable situations disproportionately affected,” the report says.

DPO, a New York–based nonprofit, launched in 1998, has sent volunteers to an average of one disaster per year, said Dr. Koyfman, also medical director for EmblemHealth Insurance, New York.

“We at DPO learn to caution folks and say, ‘Look, it’s important and it’s critical to do everything you can, but do appreciate one thing: The key is what happens 3 to 6 months from today,’ ” he said. “The mental health component will happen then. This is very different from a typical disaster mentality.”

Before the earthquake in Nepal, manpower and resources were limited: The country has about 80 psychiatrists, or about 1 for every million people, said Dr. Mahato, chief psychiatry resident, PGY-4, at Mount Sinai/Elmhurst Hospital Center, New York. After the earthquake and more than 300 aftershocks, about 2.8 million people were in need of humanitarian assistance. The DPO team partnered with the Psychiatrists’ Association of Nepal by visiting affected districts and participating in health camps. “The challenges we saw involved developing communication and training materials in a culturally appropriate framework,” Dr. Mahato said.

Portable intervention used

One intervention used by DPO teams in Nepal was Psychological First Aid (PFA), Dr. Javier Garcia said.

PFA has grown in popularity and acceptance, especially when it became increasingly clear after the attacks of Sept. 11, 2001, that psychological debriefing was not as universally useful or safe modality as it was once thought to be, said Dr. Garcia of Richmond University Medical Center, New York.

In contrast, PFA is an intervention based on principles of resilience that focuses on safety, calming, connectedness, self-community, efficacy, and hope. “PFA assumes that people can have maladaptive reactions,” Dr. Garcia said. “ But is designed to reduce the initial distress and foster short- and long-term adaptive functioning.” He said all first responders, including fire, police and crisis response teams, health care professionals, and paraprofessionals can be trained to use PFA. In fact, another model of PFA was created for school staff in the 1990s in response to school shootings.