The scientific literature has devoted little attention to characterizing patterns of delivery of mental health triage and interventions and services in the acute aftermath of a disaster or to evaluating roles of different mental health providers in any of these processes. For example, based on rather limited empirical evidence, psychological first aid was endorsed in 2002 by a consensus panel of the National Institutes of Mental Health as the approach of choice in the acute phase of a disaster.¹ The scarcity of investigations into acute interventions is in part related to the many challenges associated with conducting research in the midst of an acute disaster setting.² These include problems with designing appropriate study methods, securing rapid research funding, expeditious approval by institutional review boards, and systematic access to highly affected samples of survivors. The fact that the role of psychiatrists within the spectrum of disaster mental health providers has not been fully articulated is a likely contributor to the lack of research on post-disaster psychiatric services, including the study of pharmacologic interventions in post-disaster settings.

In this paper, we describe an approach to providing disaster psychiatric services that involved collection of clinical information as part of service delivery. The findings described below provide some characterization of acute psychiatric phenomenology, interventions, and service patterns gleaned from clinical records of the Disaster Psychiatry Outreach (DPO) 9/11 response. These data can inform a discussion of future disaster interventions by psychiatrists and other mental health professionals and future research on these interventions.

Specializing in acute, community-based response to disasters, DPO worked in conjunction with the New York City Department of Mental Health and the Red Cross to provide an organized cadre of volunteer psychiatrists to offer psychiatric assistance for individuals at the New York City Family Assistance Center (FAC). Hundreds of psychiatrist volunteers responded, and thousands of hours of pro-bono care were provided to people affected by the disaster at this site. Many volunteers (n = 75) attended a pre-deployment formal training session, consisting of a review of the psychiatric epidemiology of disasters, treatment of acute trauma, and collaboration with disaster service agencies; many others received on-site training in the setting of pressing need and a flood of spontaneous volunteers. At the FAC, from September 12, 2001 through November 20, 2001, DPO psychiatrists conducted outreach, crisis counseling, and full evaluations. Over 2000 brief encounters (which were largely anonymous and supportive in nature) were recorded in a log but are not the focus of this article. Contacts of DPO volunteer psychiatrists with disaster survivors for evaluations were initiated through a variety of mechanisms, including self-referral and referrals from other governmental and non-profit agencies. In addition to individuals who presented to the psychiatrists, some psychiatrists identified additional individuals who could benefit from an evaluation by approaching social service agencies within the FAC and identifying individuals who appeared to be having difficulty or who were visibly distressed. DPO provided frequent educational outreach about available services to many of the agencies within the FAC, which served as the main source of referrals. Goals of the psychiatric encounters were evaluation, support, limited treatment, triage, and referral.

The FAC was operated by the New York City mayor’s office and provided an array of social, economic, legal, and health services at a single site that was the length of several football fields. Other agencies that were present included the Federal Bureau of Investigation, the Red Cross, insurance companies, and the American Society for the Prevention of Cruelty to Animals. In the course of its 9/11 response at the FAC, DPO asked its psychiatrist volunteers to complete one-page evaluation sheets providing systematic information on all individuals for whom they completed a standard psychiatric evaluation. This evaluation sheet asked about history of current problems, psychiatric and social history, mental status examination, diagnostic impressions, and treatment recommendations. These forms were developed within days of the 9/11 attacks after it became apparent that efficient record keeping of clinical encounters was important within the high-intensity, high-volume environment of the FAC. Systematic diagnostic assessment was not conducted, and therefore the clinical diagnostic impressions collected merely reflect the observations of these psychiatrist clinicians in this post-disaster setting.

Psychiatrist volunteers were provided with a list of referral sources for individuals they encountered, and were encouraged to make appointments through existing mental health channels for patients needing additional services. Because the DPO psychiatrists would not be the providers of ongoing care, a decision was made to restrict samples available at the FAC to a sedative and anhypnotic to address short-term needs. Wyeth-Ayerst Pharmaceuticals donated samples of zaleplon, a nonbenzodiazepine sleep medication, and lorazepam, a sedative benzodiazepine anxiolytic, for short-term symptom management. DPO focused on acute triage and evaluation and referral of patients to pre-existing community providers for ongoing services whenever possible.

Beginning in April, 2002, volunteer psychiatrists made telephone follow-up calls to contacts from the FAC operation. These were conducted to assess the course of those who had received DPO services in the first weeks following 9/11 and to provide further assistance in obtaining additional care and accessing other resources.

The encounter form prompted volunteer psychiatrists to record their clinical impressions in open-ended text. Data were extracted from the completed forms and entered into an Access database containing demographic, credentialing, and professional information about volunteers, and identifiers matching providers with contacts for data analysis. Information about follow-up contacts was also entered into the patient database. To create the database for this study, Access files representing clinical information were transformed into SAS datasets and merged using identification codes unique for each individual and for each contact.

Results are summarized using tabulations, raw numbers, and percentages for categorical variables and means with standard deviations (SDs) and ranges for numeric data. Denominators providing the number of observations are indicated wherever there are missing data. Comparison of categorical variables involved chi-square analysis (substituting Fisher’s exact tests for comparisons with one or more cells with expected values of less than 5). Comparison of categorical with numerical variables was performed with two-tailed Student’s t-tests, using Satterthwaite comparisons when equality of variance assumptions were not met.

The number of diagnoses of PTSD made less than a month after the trauma suggests that psychiatrists responding to future disasters could benefit from more intensive training prior to deployment and from the development and implementation of tools that ensure more systematic and accurate diagnostic assessment. Even without more definitive data, the fact that these psychiatrists identified a large number of individuals who were distressed and perceived as having diagnosable psychiatric disorders and being likely to benefit from medication and referral for ongoing care, suggests a potential need to expand acute disaster mental health services to specifically include services that can be provided by psychiatrists.

The experience of DPO after 9/11 demonstrates that both psychiatric clinicians and researchers may make meaningful contributions to their communities and to our collective understanding of people’s mental health responses to disasters. The scale of this volunteer service suggests the potential for humanitarian and scientific benefits when psychiatrists come together before events to plan and develop training, clinical infrastructure, record keeping, and practical and ethical scientific methodology. With further refinements—such as prompts to record specific symptoms and their onset—systematic clinical record keeping has the potential to serve as a model for future studies in settings where more rigorous research methodologies may not always be feasible.

Experience of the mental health response after Hurricane Katrina, described in a recent publication,⁴ further substantiates that psychiatrists can be integrated into a disaster mental health response, and illustrates that provision of psychotropic medications is not only possible but important in the acute aftermath of disasters. Examination of acute psychiatric services provided to Hurricane Katrina evacuees demonstrated a distinct need for volunteers with psychiatric expertise. Many individuals served by mental health clinicians in this disaster had pre-existing severe and persistent mental illness, needed major psychotropic medications (antipsychotic, antidepressant, mood-stabilizing, and anxiolytic agents as well as specialized medications such as methadone maintenance), and had comorbid medical conditions, many of which (e.g., delirium, dementia, and substance abuse-related states such as psychosis) required differentiation from psychiatric illness. Provision of services for these needs is a function specific to psychiatrists.⁴

There are several important limitations of this study, most importantly the variable and limited quality of the clinical data collected. Given the lack of uniform data or systematic sampling, this study cannot be used to determine epidemiological prevalence. The follow-up contacts were limited to unstructured impressions and no follow-up information was obtained for many individuals. Therefore, these follow-up data do not indicate the relative effectiveness of the interventions provided; substantially greater efforts to accomplish this would be needed to gather meaningful outcome results in evaluating future post-disaster outreach. The diagnosis of PTSD prior to 4 weeks of symptoms raises questions about whether clinicians were identifying pre-disaster cases or whether they were ignoring the DSM-IV-TR duration criteria. Clinicians’ divergence from optimal practice in these chaotic situations deserves further attention in research on psychiatric response in post-disaster settings. The deliberate choice of available pharmacotherapeutic samples determined in advance constrained medication options, therefore subverting potentially meaningful generalizations about prescribing patterns from this program. Finally, the psychiatrists in this program used their clinical judgment to determine whether to complete an evaluation or whether to conduct a brief encounter. Without data on how these decisions were made, we cannot determine how the sample described in this study differs from other individuals who sought help in this setting.

Although expert consensus guidelines have recommend SSRIs as first-line agents for ongoing treatment of PTSD⁵ and some reports have recommended medications for prevention of PTSD, samples of SSRIs were not stocked at the FAC given the early timeframe for these evaluations and a lack of certainty that these individuals would engage in the systematic follow-up that is indicated when starting ongoing medication. The goal of DPO’s psychopharmacologic interventions was short-term relief of anxiety and insomnia, which could be viewed as a psychopharmacologic equivalent of “psychological first aid.” There is no reliable randomized evidence about the effects of soporifics or anxiolytics in the acute post-trauma setting when the goal is short-term symptom relief. The short-term intent is underscored by the fact that the average number of pills prescribed was five. Despite the lack of reliable evidence either way, psychiatrists functioning in an acute post-disaster environment often do so in an atmosphere that is colored by notions that prescription of psychotropic medications may impair normal psychological processing of trauma and grief.⁶ More systematic research is needed concerning the use of such medications in a real-world acute response, as well as further consideration of the ethics of involving pharmaceutical companies in the donation of samples.