Rapid Assessments of Mental Health Needs After Disasters

Abstract

THE RAPID NEEDS ASSESSMENTS UNDERTAKEN AMONG adults and children 8 weeks after the December 2004 tsunami in Thailand and the results of these assessments reported in this issue of JAMA by van Griensven and colleagues and by Thienkrua and colleagues mark an impressive advance in the field of psychiatric epidemiology. Strengths of these investigations include the timeliness of the studies, the prominent role played by Thai researchers, the application of rigorous sampling methods, and the inclusion of international and culture-specific indices of distress. In addition, 9-month follow-up data are provided, a rare achievement in disaster research undertaken in the developing world. These studies demonstrate both the feasibility and value of undertaking rapid needs assessments to guide mental health planning after disasters. Yet critics continue to question if and how psychological trauma affects the mental health of disaster-affected populations, challenging the validity of the key diagnostic category of posttraumatic stress disorder (PTSD), particularly when applied across cultures. Screening for PTSD among survivors of disasters in developing countries, especially in acute situations, has faced a number of common criticisms, including the following: psychological trauma is a western concept that may be unfamiliar to other cultures; PTSD has limited diagnostic validity because culturally diverse communities do not have equivalent terms for the constellation or for the individual symptom domains of the disorder; measuring traumatic stress across societies can yield misleading results, since the meaning of “symptoms” may differ across cultures; disaster-affected communities may not identify psychological stress as a priority need, as they may be more concerned with practical and social needs; a diagnosis of PTSD may encourage a culture of “victimhood” and passivity, potentially inhibiting communities from adopting an active approach to recovery; traumatic stress “symptoms” may be normative coping mechanisms and do not necessarily lead to disability or impairment; an emphasis on PTSD may encourage an individual and clinical focus, creating unrealistic expectations that all survivors should receive counseling; there is limited evidence that treatments for PTSD developed and tested in the West are effective across cultures and importing techniques from the West may undermine traditional healing mechanisms; attention to social, material, economic, cultural, and human rights issues may be more important in facilitating natural recovery at a group level; and the emphasis on PTSD may obscure other pressing mental health needs. Debate on the issue is widespread, with some experts emphasizing the importance of treating PTSD after disasters and others highlighting more pressing mental health priorities. The ongoing controversy risks confusing funding agencies and other donors, as well as those responsible for planning mental health programs as part of humanitarian relief efforts following disasters. The Thailand-based studies by van Griensven et al and Thienkrua et al add to a growing body of research indicating that PTSD symptoms can be identified both in adults and in children across cultures. The key question, however, is whether the prevalence of PTSD symptoms in the immediate aftermath of disasters offers valid information and reliable direction to guide local mental health planning. The study of adult tsunami survivors by van Griensven et al yielded prevalence estimates for PTSD symptoms ranging from 7% to 12% at 8 weeks after the tsunami, with higher rates of symptoms of anxiety and depression. If these values are extrapolated to the wider tsunami-affected region, the numbers with PTSD symptoms would run into the several millions. If it is assumed that all these persons were disabled and in need of urgent mental health care, existing psychiatric services would clearly not have the capacity to meet the demand. An important question, therefore, is how these high rates of trauma-related mental symptoms occurring soon after the disaster should be interpreted. In both Thai studies, the psychiatric indices were defined solely by the endorsement of symptoms, a method that might inflate prevalence rates unless psychosocial impairment is measured concurrently. For example, in Thailand, a fisherman who has intrusive memo-