Based on the decision analysis framework described here, we estimated that universal provision of an evidence-based mental health intervention model to the population affected by a disaster such as the 2005 Gulf storms would cost on the order of $1,133 per capita across the affected population in months 7-24 post-disaster, with nearly half of this spending in months 7-12 due to an initial surge in need. In turn, we estimated that the services purchased by this money would reduce the number of six-month episodes of storm-attributable mental health problems by 35%, corresponding to a per capita average of two extra months spent free of mental illness for each person in the disaster-affected population.
Given the structure of our model, varying the overall level of implementation of the proposed interventions would reduce both costs and benefits in approximately equal proportion. Thus, for instance, 25% coverage (vs. zero) would cost $347 per capita over 7-24 months (30.6% of the cost of 100% vs. zero coverage), and avert 102 six-month episodes of illness (31.0% of 100% vs. zero). This correspond to a cost per averted episode of $3,416, vs. $3,460 for 100% vs. zero; this difference is because, under less than universal coverage, a smaller proportion of treatment episodes are provided to refractory patients. Similarly, if the base rate of treatment were 25%, moving to 100% yields a cost per averted episode of $3,549, or $3,535 to move to 70% coverage. Other permutations would likely shift this balance unfavorably, for instance if some people who initiate treatment discontinue early: they would consume services, and incur costs, when they start treatment, but then discontinue treatment before is (fully) therapeutic.
Formal estimation of cost-effectiveness was outside the scope of this study. Prior studies have mapped episodes of mental illness to quality-adjusted life years in order to provide a general framework for considering cost-effectiveness (27
), in particular, using evidence from methodological studies that depression reduces the value of a quality-adjusted life year (QALY) by 0.2 to 0.4 (out of a maximum value of 1). (29
) If we apply these scaling factors to episodes of mental illness in our model, our estimated cost per averted episode corresponds to an estimated cost per QALY of $17,301 to $34,603. Even the upper end of this range – to be conservative – is within the range of generally accepted medical practice, such as regular screening for colorectal, prostate, and breast cancers in average-risk patients, and blood pressure screening among normotensive people. (31
Our intervention cost and outcome estimates are likely to be upper bounds, for several reasons. Our reference population was zero treatment (natural illness recovery) whereas “usual” care would include some delivered services. Yet this may not be so out of range as many affected people may choose not to receive mental health services even if offered, due to stigma, cultural acceptability of services, competing needs, and other factors. The Gulf storms, in particular, disproportionately affected racial/ethnic minority and low-income populations, which tend to have less access to and lower use and quality of mental health treatment. (12
This raises the issue of feasible implementation. Assuring the delivery of evidence-based mental health interventions can be challenging in the absence of a disaster. Moreover, there is evidence that demand – or at least clinical need – for mental health services exceeds the available supply in many parts of the country, even without surges in need following a disaster. (35
) In the US public sector mental health providers are primarily oriented to persons with severe and persistent mental illness, such as schizophrenia; while private sector systems may be more familiar with disorders like depression that are common after disasters but have limited experience caring for disadvantaged or displaced populations – and often little mandate to do so. In addition, there is generally weak infrastructure for reliably delivering the types of psychotherapy such as CBT that are known to be effective in post-disaster situations.
Our findings suggest that population-level implementation would almost certainly exceed local provider capacity. While disaster preparedness may help motivate some expansion of local capacity, it is unlikely to be feasible or efficient for each geographic area to have adequate local reserve resources to meet post-disaster needs. Instead, response could draw on national reserve resources. Indeed, outside human and other resources played an important role in response to the Gulf storms; yet those resources were largely assembled after the storms had occurred and needs identified. Response to future disasters may be substantially enhanced if it could draw on a pre-established national “ready reserve” of providers trained in evidence-based treatments, along with a logistical infrastructure to deploy them effectively – in-person and via telehealth – and to coordinate their work.
We emphasize that “national” need not mean “public”. In practice, along with the Veterans Administration and the Department of Defense, the largest existing networks of mental health providers – in terms of both number of providers and geographic coverage – are those of private MBHOs, which may also have relevant managerial and logistical capabilities and experience. Disaster preparedness is now considered a public good, and national mental health preparedness will likely require some federal sponsorship for financing, as well as to establish the parameters for a national mental health response, develop the rules under which it would operate, activate/deploy the response infrastructure, and monitor outcomes.
Telehealth through available large managed care companies seems like a natural fit with the goal of achieving a nationally distributed network of “reserve” providers; and a growing body of research supports telephone psychotherapy as a viable delivery option. (22
) However, further research is needed to assess the effectiveness of telephonic mental health response in post-disaster settings, and to identify operational requirements such as referral mechanisms, clinical supervision, outcome monitoring, and billing/reimbursement for population-based care.
One particular local supply issue we identified was a likely shortage of inpatient beds and the associated clinical staff; addressing this shortage would require new structural resources such as psychiatric wards in field hospitals and/or evacuating patients to facilities outside the affected area that have extra capacity. Further research is also required to establish best practices for meeting these service delivery needs.
Policy changes are likely to be required to facilitate a 2-year response by providers from outside a disaster-affected area. In general, providers must be licensed in the state in which they are providing services, or be federally certified (e.g., employed by the Veterans Administration or the US Public Health Service), neither of which covers the majority of potential responders from outside a disaster-affected area; or the services can be classified as nonprofessional or educational, neither of which is generally germane here. In the case of the Gulf storms, some of the affected states waived licensure requirements some professions. In Louisiana, some waivers were maintained after the storms for provider groups that do not charge for services in the affected areas. However, these responses occurred somewhat ad hoc and mostly after the fact. Based on the experience following the Gulf storms, it may be appropriate to consider developing a standard national strategy to streamline licensing and malpractice issues, e.g., by allowing providers licensed anywhere in the US to practice in any FEMA-designated disaster area for a specified period of time, along with a viable mechanism to provide malpractice coverage to providers who participate in disaster response. Similarly, modification or extension of policies affecting medical licensing and malpractice are likely to be needed to facilitate telecare, both to cover cross-state provision of care and to enable reimbursement.
Other methods to consider for increasing supply rapidly may include rapid retooling of providers for other kinds of health or social services, and/or training and deployment of nonprofessional/lay providers; and developing a deeper local reserve of community leaders with relevant skills who could participate in response to local community emergencies. Some such innovations might additionally strengthen community mental health resources in non-disaster circumstances, a “dual use” that has been emphasized in other areas of preparedness.
Until the recent primary care authorization for New Orleans, potentially including support for behavioral health services, there was no specific federal allocation for mental health services in response to the Gulf storms. This raises the question of the priority that should be given to mental health response, given many competing recovery needs. The Gulf storms have dramatically illustrated the scope and persistence of mental distress, which cuts across age and cultural groups, and is likely to impede many aspects of both individual and community recovery, even as research has shown economic benefits from mental health interventions. (38
We have focused on mental health recovery over months 7-24 post disaster, and additional strategies may be required to promote longer-term improvements subsequently. For example, while chronic disease management programs for depression improve outcomes, disseminating and sustaining these interventions outside of a disaster has been difficult, as key components are often not covered by insurance policies. Similarly, many schools were found to have adequate crisis response plans post-Katrina, but few had the resources to sustain provision of mental health services. (39
) Yet even investing in short-term interventions may have long-term health benefits over many years for disadvantaged population groups. (40
) Thus, we currently face the option of proactively developing a plan to intervene quickly following disasters – beyond current efforts, most notably crisis counseling – to promote mental health recovery for survivors; we wonder whether this would facilitate recovery in other life domains; and suggest that it is important to determine how to promote long-term recovery for individuals and communities.
More generally, we have taken a largely medical perspective on ameliorating mental health consequences of disasters. Comprehensive disaster response requires intervention across multiple domains, including short- and long-term efforts to ensure survivors' mental, physical, social and economic needs. While there are likely to be powerful synergies across these domains, we recognize that the optimal mix of interventions across them remains an open question. We necessarily leave this to future research.
A key related issue is when and for whom to activate this type of intervention program. In principle, the framework described here could be applied for disasters of varying scope and scale. In practice, the intervention details will vary by the scope, scale, nature and consequences of the disaster, e.g., depending on the extent of population displacement and on how the needs in an area exceed its available/remaining delivery system capacity.
Our analyses have important limitations. There are many knowledge gaps regarding “evidence-based” response to disasters and a recent report by the Institute of Medicine highlighted concerns about insufficient evidence of efficacy for most treatments for PTSD among adults. (21
) Our models could not include data on individual differences in response to traumatic events, which are key predictors of outcome; so we present a population rather than individual perspective on services that promote recovery. There is some degree of uncertainty around each of the model's many inputs, and thus our overall findings. We focused on the context of the Gulf storms, and estimates for other disasters could require different assumptions and yield different results; but we designed the treatment and per-capita services model to be applicable across a wide range of contexts.
Given the recent evidence of high burden of disease and significant unmet need among the survivors of the Gulf Storms, and widespread discussion of disaster preparedness more generally, we hope that the response model proposed here may be a useful starting point for policy discussions, to improve services for people with persistent illness following the Gulf storms, as well as to plan a coordinated response strategy for future disasters.