Mental health assistance to the populations affected by the Tsunami in Asia
Introduction and Population perspective
Persons affected by a catastrophe like the tsunami of 26 December are exposed to extreme stressors (personal danger, loss of kin, etc.). These stressors do represent risks for mental health problems. Basic social and mental health interventions – on which there is broad consensus - should be implemented before more specialized interventions are considered.
WHO has received numerous generous offers from individuals and organizations to assist in mental health field missions, trauma training and the organization of meetings to discuss mental health strategies. We are thankful for the many offers of help that we have received.
Through the years, WHO and its staff have accumulated experience and knowledge on post-disaster activities. We have published a number of documents that summarize our advice, which is based on experience and the scientific literature. These documents are applicable to a variety of crises, whether caused by natural disaster or conflict.
In January we conducted extensive on-site assessments in Indonesia, Sri Lanka, Maldives (and co-incidentally in conflict-affected Darfur), which has reaffirmed our perspective of what should be done in terms of psychosocial/ mental health assistance after large scale disasters, such as the present one. Our work in countries has focused on assisting the Ministry of Health of Indonesia, Maldives and Sri Lanka in assessing, planning and coordinating activities in the health sector.
A population perspective
Viewing the situation from a public health perspective (i.e., a population perspective), rather than a clinician's perspective, we see the situation as follows.
Although there are no reliable data on numbers of people with mental health problems in the tsunami-affected countries, the following rule-of-thumb estimates give context to the likely size of the problem. These rates vary with setting (e.g. involving sociocultural factors, current and previous disaster exposure) and assessment method and give a very rough indication of what WHO expects the extent of morbidity and distress to be. We see three groups each requiring a different response:
1. People with mild psychological distress that resolves within a few days or weeks
A very rough estimate would be that perhaps 20-40% of the tsunami-affected population falls in this group. These people do not need any specific intervention.
2. People either with moderate or severe psychological distress that may resolve with time or with mild distress that may remain chronic
This group is estimated to be 30-50% of the tsunami-affected population and covers the people that tend to be labelled with psychiatric diagnoses in many surveys involving psychiatric instruments that have not been validated for the local cultural and disaster-affected context. This group would benefit from a range of social and basic psychological interventions that are considered helpful to reduce distress. (These interventions - which are generally made available to anybody (whether or not they have disorder) in a variety of sectors - tend to be called 'psychosocial' by humanitarian and development workers. Traditionally mental health specialists have used the term 'psychosocial intervention' to describe non-biological mental health interventions for people with mental disorders, which is in contrast to the way the term 'psychosocial' is used these days by humanitarian and development workers.)
3. People with mental disorders - mild and moderate mental disorder
In general populations, 12-month prevalence rates of mild and moderate common mental disorders (e.g., mild and moderate depression and anxiety disorders, including PTSD) are on average about 10% in countries across the world (World Mental Health Survey 2000 data). This rate is likely to rise - possibly to 20% - after exposure to severe trauma and resource loss. Over a number of years, through natural recovery, rates may go down and settle at a lower rate, possibly at 15% in severely affected areas. Thus, in short, as a result of disaster, the population rates of disorder are expected to increase by about 5-10%. A misconception is that PTSD is the main or most important mental disorder resulting from disaster. PTSD is only one of a range of (frequently co-morbid) common mental disorders (mood and anxiety disorders), which tend to make up the mild and moderate mental disorders, and which become more prevalent after disaster. The low-level of help-seeking behaviour for PTSD symptoms in many non-western cultures suggests that PTSD is not the focus of many trauma survivors. Consequently, WHO is concerned that agencies are over-emphasizing PTSD and are creating narrowly defined, vertical (stand-alone) services that do not serve people with other mental problems. This way of working could waste precious resources.
4. Severe mental disorder
Severe mental disorder that tends to severely disable daily functioning (psychosis, severe depression, severely disabling anxiety, severe substance abuse, etc.) is approx. 2-3% in general populations of countries across the world (World Mental Health Survey 2000 data). People with these disorders may experience inability to undertake life-sustaining care (of self or of their children); incapacitating distress; or social unmanageability. The 2-3% rate may be expected to go-up (e.g. to roughly 3-4%) after exposure to severe trauma and loss. Trauma and loss (a) may exacerbate previous mental illness (e.g., it may turn moderate depression into severe depression), and (b) may cause a severe form of trauma-induced common mental disorder in some people.