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BMJ. 2007 October 6; 335(7622): 679–680.
Published online 2007 September 18. doi:  10.1136/bmj.39329.580891.BE
PMCID: PMC2001060

Mental health in disaster settings

Lynne Jones, senior mental health adviser, International Medical Corps,1 Joseph Asare, private consultant psychiatrist,2 Mustafa Elmasri, mental health officer,3 and Andrew Mohanraj, psychosocial programme director4

New humanitarian guidelines include the needs of people with severe mental disorders

Guidelines on mental health and psychosocial support in emergency settings were launched in Geneva last week by the Inter-Agency Standing Committee (IASC).1 They will provide guidance on protecting and promoting the mental and social wellbeing of all people affected by emergencies created by conflict or natural disasters. Among the many topics covered, the guidelines also give special attention to people with severe mental disorders in the community.

Mental disorders account for four of the 10 leading causes of disability worldwide.2 Yet mental health is one of the most under-resourced specialties, and no country meets its mental health needs even when no emergency exists.3 In emergencies, the proportion of people with severe mental disorders (such as psychosis or severely disabling moods, anxiety, and stress related disorders) is projected to be about 1% higher than the estimated baseline of 2-3%.4 In a large emergency this can amount to thousands of people.

People with severe pre-existing mental disorders are particularly vulnerable.5 6 A pre-existing disorder may be exacerbated by stressful events, by disrupted supplies of drugs, and by the lack of social support that previously sustained these people. Established traditional means of care, such as those provided by local spiritual healers, may not function. Patients in institutional care may be abandoned by the staff and the institution itself may be targeted, taken over, or destroyed. People with severe mental disorders may not understand the risk of remaining in their surroundings, or they may be abandoned by their families and communities. If they can be persuaded to escape, they may be chained, stoned, and exposed to life threatening situations in refugee camps. They are also without adequate care and protection because of a lack of drugs and trained staff. Stigma may cause families to hide a family member who is mentally ill, so the person is unable to speak for themself.

Community interventions for people with severe mental disorders in emergencies include assessing existing services and identifying those in need; building a relationship with healers and facilitating the use of supportive traditional healing methods where appropriate; ensuring sustainable supplies of psychotropic drugs; initiating rapid training and ongoing supervision for emergency primary healthcare staff; and establishing an accessible advertised service while avoiding the creation of parallel mental health services focused on specific diagnoses (such as post-traumatic stress disorder) or on narrow groups (such as widows). The service should provide basic biological and psychosocial interventions to relieve symptoms and restore function; educate and support existing carers; work with local community structures and groups to enable protection of people who are severely disabled by mental disorder; plan for the return home of any displaced people; and collaborate with existing health services and authorities to create sustainable care.

These recommendations are described in one of the guidelines' 25 action sheets that describe the minimum interventions needed in numerous sectors during an emergency. The range of topics covered shows that mental health and psychosocial support in emergencies should be considered when providing education, water, shelter, food, and community support, as well as health care.

The guidelines were developed by a task force of representatives from 27 international governmental and non-governmental organisations, who consulted with experts from more than 100 non-governmental organisations, academic institutions, and professional organisations in English, French, Arabic, and Spanish.

The guidelines represent the first attempt at a global consensus on recommended practices by aid agencies. This is an advance from 1998, when the inability to achieve consensus meant that mental health was excluded from the first edition of the Sphere minimum standards for humanitarian response. (A brief standard on mental and social health was included in the last edition of Sphere.7)

The guidelines include underlying core principles emphasising an approach that protects the human rights of all affected persons, treats them with equity, maximises their participation in the emergency response, emphasises building on local capacities, and takes the principle of “do no harm” as a point of departure. This is particularly important given the continuing limited quantitative evidence base for many of the mental health interventions introduced in disaster settings.8 9

The guidelines recognise that populations living through conflict and disaster are initially helped most by social interventions that deal with their basic needs, re-establish social networks, and allow them to restart their lives. These interventions should also incorporate humane, culturally appropriate supports for specific subpopulations, including protection and clinical care of people with severe mental illness. This holistic approach requires an integrated, multisectoral response, in contrast to the fragmentation of care that has characterised many emergencies in the past.10 The challenge for agencies in the field is to work collaboratively to unite the different sectors involved in mental health and psychosocial support.

Notes

Competing interests: LJ is a member of the IASC task force that wrote the guidelines. JA, AM, and ME were part of the global consultation group that reviewed the guidelines.

Provenance and peer review: Not commissioned; externally peer reviewed.

References

1. Inter-Agency Standing Committee (IASC). IASC guidelines on mental health and psychosocial support in emergency settings 2007. www.humanitarianinfo.org/iasc/mentalhealth_psychosocial_support [PubMed]
2. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CL, eds. Measuring the global burden of disease and risk factors, 1990-2001. New York: Oxford University Press, 2006
3. WHO World Mental Health Survey Consortium. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization world mental health surveys. JAMA 2004;291:2581-90. [PubMed]
4. Van Ommeren M, Saxena S, Saraceno B. Aid after disasters. BMJ 2005;330:1160-1. [PMC free article] [PubMed]
5. Silove D, Ekblad S, Mollica R. The rights of the severely mentally ill in post-conflict societies. Lancet 2000;355:1548-9. [PubMed]
6. Silove D, Manicavasagar V, Baker K, Mausiri M, Soares M, de Carvalho F, et al. Indices of social risk among first attenders of an emergency mental health service in post-conflict East Timor: an exploratory investigation. Aust N Z J Psychiatry 2004;38:929-32. [PubMed]
7. Sphere Project. Humanitarian charter and minimum standards in disaster response. 2004. www.aai.org.au/resources/publications/SphereHandbook.pdf [PubMed]
8. Patel V, Araya R, Chatterjee S, Chisholm D, Cohen A, De Silva M, et al. Treatment and prevention of mental disorders in low and middle income countries. Lancet (in press).
9. Morris J, van Ommeren M, Belfer M, Saxena S, Saraceno B. Helping children in crisis: a child-focused review of the Sphere standard on mental and social aspects of health. Disasters 2007;31:71-90. [PubMed]
10. Van Ommeren M, Saxena S, Saraceno B. Mental and social health during and after acute emergencies: emerging consensus? Bull World Health Organ 2005;83:71-5. [PubMed]

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