Following disasters, UK survivors’ psychosocial needs are looked after by local authorities, possibly supplemented, since 2005, by a multi-agency “humanitarian assistance centre”. These centres come under the remit of the humanitarian assistance unit at the Department of Culture, Media, and Sport. People with acute mental health problems are treated by existing emergency and psychiatric services.
Whereas many survivors of disasters will develop transient post-traumatic symptoms, most will recover naturally, and only a minority will require more intensive intervention.
Early single-session interventions such as psychological debriefing, which aims to have all survivors talk about their experiences, have not been found to be effective and are not recommended by the National Institute for Health and Clinical Excellence (NICE Guideline on the Management of PTSD in Adults and Children in Primary and Secondary Care).
“Psychological first aid” is less intrusive and consists of fulfilling immediate needs for safety, shelter, and information. It also offers an opportunity to identify survivors so that they can later be registered, screened, offered follow-up services, etc. Mental health services should be involved in ensuring that any immediate interventions that are offered are appropriate and conducted by suitably trained personnel.
The most common psychological conditions caused by disasters are post-traumatic stress disorder (PTSD), depression and anxiety. Where there has been loss of life, abnormal grief reactions are likely among survivors and bereaved relatives. There is abundant evidence, however, that it is difficult to identify this minority of survivors and relatives, and they are unlikely to be referred by GPs to mental health services due to their avoidance symptoms, and due to low levels of familiarity with these conditions among both survivors and professionals.
In order to overcome these anticipated barriers to treatment, a systematic screen and treat programme was implemented immediately following the London bombings of July 2005.
A clinician-led collaboration between specialist NHS post-traumatic stress services and the London Development Centre for Mental Health (part of the Care Services Improvement Partnership) proposed an integrated pan-London programme to the Department of Health.
The programme consisted of: (a) a central screening team who were charged with contacting and screening survivors of the bombings, and where appropriate assessing and referring them to specialist psychological trauma services; (b) additional clinical psychologists who delivered NICE-approved treatment for PTSD and other conditions.
The programme was approved and ran from September 2005 to September 2007. The main lessons of the programme are set out below.
- Fears about the acceptability of mental health staff contacting survivors by letter or telephone proved to be unfounded and contact was almost invariably positively received. There was no evidence of any adverse consequences or distress caused by the offer of screening, even among those who did not want to take up the offer. The programme succeeded in identifying, screening and referring a large number of patients, and treatment was associated with substantial symptom reduction comparable with the results of previous RCTs.
- Major difficulties were encountered in locating the names and contact details of affected individuals, and this had a negative impact on the effectiveness of the programme. Levels of awareness of the programme were relatively low where respondents were written to by a third party such as the Metropolitan Police, and there was evidence of persistent traumatic stress symptoms in a substantial minority of this group, who were likely to attribute their failure to use the programme to lack of knowledge of its existence.
- Unwarranted concerns about the Data Protection Act prevented data sharing, even within different parts of the NHS. Relevant guidance has now been issued by the Cabinet Office (see link below), and the principles should be understood by all parties involved in local emergency planning (including mental health services). Discussions are currently under way between the Department of Health emergency preparedness division and the Health Protection Agency to make the HPA responsible for compiling a list of individuals affected by disasters and sharing this with appropriate partners.
- The central screening team was an effective way of contacting affected individuals and ensuring their access to treatment regardless of their locality. Given the failure of normal care pathways that was observed, particularly that involving general practitioners, an outreach programme carrying out repeated screening should be considered as part of the psychosocial response to future disasters and mass casualty events.
- The requirement to provide equal access to evidence-based psychological treatment for a population of geographically dispersed individuals was in conflict with most established local mental health care pathways and funding mechanisms. Trust chief executives and strategic health authorities need to be aware of these problems in advance, and to model them as part of emergency planning exercises. Normal financial and geographic arrangements governing access to mental health services are likely to greatly impede the delivery of services to those affected by a disaster. Considerable administrative efforts are likely to have to be devoted to setting up and ensuring the effectiveness of new care pathways. These activities will themselves need to be budgeted for.
- There is an absence of established guidelines for setting up and arranging funding for additional mental health services in response to unforeseen emergencies, and trusts may need to proceed “at risk” without budgetary guarantees. Department of Health guidance is needed to specify the appropriate financial procedures to follow when expenditure on mental health is necessary for emergencies that have not been budgeted for. This guidance may need to be discussed with the independent regulator of NHS foundation trusts, Monitor, and other relevant bodies, to make sure that it does not conflict with their rules concerning financial accountability.
- Mental health services need to have close links in place with emergency planners and relevant organisations such as regional resilience forums. The role of mental health services needs to be recognised and accepted by other partners before the occurrence of a disaster, and close working with local authorities and humanitarian assistance centres is strongly recommended.
References and links
The report to the Department of Health evaluating the mental health response to the London bombings can be found at http://disaster.efpa.eu/
Detailed information about government structures and plans for pre- and post-disaster responding can be found at http://www.cabinetoffice.gov.uk/ukresilience/about.aspx
Cabinet Office guidance on data sharing after disasters: http://www.cabinetoffice.gov.uk/media/132709/dataprotection.pdf
NHS Emergency Planning Guidance issued July 2009 “Planning for the psychosocial and mental health care of people affected by major incidents and disasters: Interim national strategic guidance”: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_103563.pdf
NICE Guideline on the Management of PTSD in Adults and Children in Primary and Secondary Care: http://www.nice.org.uk/nicemedia/pdf/CG026fullguideline.pdf
References to the London Bombings mental health programme:
Brewin, C.R. et al. (2008). Promoting mental health following the London bombings: A screen and treat approach. Journal of Traumatic Stress, 21, 3-8.
Brewin, C.R. et al. (in press). Outreach and screening following the 2005 London bombings: Usage and outcomes. Psychological Medicine.
Professor Chris R. Brewin, clinical, educational and health psychology, University College London.