key: cord-0803044-4qhrdftc
authors: Angela Lo, Huei-Wen; Su, Chao-Yueh; Chou, Frank Huang-Chih
title: Disaster Psychiatry in Taiwan: A Comprehensive Review
date: 2012-02-22
journal: J Exp Clin Med
DOI: 10.1016/j.jecm.2012.01.005
sha: e612368342d07454fe78c19782539c09a3c2033f
doc_id: 803044
cord_uid: 4qhrdftc

Natural disasters have caused millions of deaths worldwide, and hundreds of millions of people have suffered from various types of physical or mental traumas. Disasters change patterns of thinking and the concept of security among members of a community, which highlights the importance of mental rehabilitation in disaster psychiatry. Mental rehabilitation is not only a short-term intervention, but also involves long-term follow-up and referral of cases to regular psychiatric management. We used PubMed (http://www.ncbi.nlm.nih.gov/pubmed) to search for papers related to the Chi-Chi Earthquake and the Morakot Typhoon published between January 2001 and November 2011. We found that 33 articles are involved in seven topics. The most common disaster-related psychiatric diagnoses were major depressive episodes and posttraumatic stress disorder. The prevalence of posttraumatic stress disorder ranged from 8.0% to 34.3% in Taiwan after the 1999 Earthquake. However, lifetime and current prevalence for psychiatric disorders ranged from 1% to 74%, affecting women twice more than men. Because disasters are becoming increasingly common, it is vital to train a sufficient number of specialists with guidelines for standard clinical treatment, and to create a standard operating procedure for reducing traumatic conditions.

In the past two decades, natural disasters have caused millions of deaths worldwide, and hundreds of millions of people have suffered from various types of physical or mental traumas. The 9/11 terrorist attacks in the United States in 2001 caused worldwide panic; the 2004 Richter scale 9 earthquake and tsunami in South Asia resulted in hundreds of thousands of casualties in coastal areas, and the 2008 earthquake in Sichuan, China, claimed hundreds of thousands of casualties. In the past 10 years, Taiwan has been hit with various small-scale disasters such as traffic accidents, airplane crashes including crashes of China Airlines and Singapore Airlines, train derailment of the Alishan Railway, as well as the collapse of the Pingtung Bridge and the Lincoln Mansions in Taipei County. In addition, Taiwan has experienced several largescale disasters, including the catastrophic destruction produced by the Chi-Chi Earthquake in 1999, the Severe Acute Respiratory Syndrome epidemic in 2003, the 8/8 floods in southern Taiwan in 2009, and the Morakot Typhoon, which resulted in the tragic destruction of Xiaolin village. Because of their geographic location, many Asian countries are at a higher risk for natural disasters. According to statistical data from the Red Cross Society, Asia is more disaster-prone than any other areas in the world. 1 Repeated disasters alter thinking patterns and the concept of security within a community. The recent onslaught of disasters highlights the need for disaster psychiatry and the importance of mental rehabilitation. 2 

Neria et al classified disasters into three categories: (A) man-made disasters, (B) technological disasters, and (C) natural disasters, which affect millions of people around the world every year. Natural disasters (e.g., earthquakes and hurricanes) and man-made disasters (e.g., traffic accidents, acts of terrorism, and wars) can cause psychological trauma with long-lasting consequences. 3e6 The impact of a mass disaster or man-made trauma on an individual is a composite of two major elements: (A) the catastrophic event itself and effects of media coverage and (B) the vulnerability of the individual affected by the event. Affected individuals may include survivors, rescue workers, and vulnerable populations affected by media coverage. 7e9

Many studies 10e14 have shown evidence of psychological sequelae in disaster survivors, including posttraumatic stress disorder (PTSD), major depressive episodes (MDE), substance abuse, sleep disorders, anxiety, panic attacks, and other symptoms. The most common disaster-related psychiatric diagnoses are MDE and PTSD, which are closely associated, 2e5,12e26 and this continues to gain attention in trauma outcome research. 4 In addition, rescue workers such as nurses, firefighters, and soldiers incur a high prevalence of psychiatric disorders after disaster rescue. These individuals would also benefit from mental rehabilitation. 7,27e30

A systematic review of PTSD following disasters by Neria et al 6 concluded that the post-disaster burden of PTSD is substantial.

According to the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria, PTSD has three core psychopathologies: (A) reexperience, (B) numbness and avoidance, and (C) hyper-arousal. The DSM-IV diagnostic criteria for PTSD allow clinicians to specify whether the disorder is chronic (if the symptoms have lasted 3 months or more) or exhibits delayed onset (if the onset of symptoms was 6 months or more after the stressful event).

The prevalence of PTSD ranged from 8.0% to 34.3% in Taiwan after the 1999 earthquake, 15, 16 measured about 25% in Turkey after the 1999 earthquake, 31 and was reported to reach as high as 74% in Armenia after the 1988 earthquake. 32 In a systematic review of the literature, Andrews et al 33 found that delayed-onset PTSD in the absence of any previous symptoms is rare, whereas a delayed onset that represented an exacerbation or reactivation of prior symptoms accounted for 38.2% and 15.3% of military and civilian cases of PTSD, respectively. Generally, the lifetime and immediate prevalence rates for psychiatric disorders range anywhere from 1% to 74%, 34e38 affecting women twice more than men. Furthermore, women report more symptoms of anxiety and depression than men. 36, 37 6. Publications related to disaster in Taiwan acquired from a from a PubMed search

We used PubMed (http://www.ncbi.nlm.nih.gov/pubmed) to search for papers related to the Chi-Chi Earthquake and the Morakot Typhoon, published between January 2001 and November 2011, and found 33 in total. The topics of articles cover: (A) prevalence of and risk factors for psychiatric disorders in different groups, (B) establishment of screening tests, (C) quality of life in survivors, (D) suicide rates following the disaster, (E) the effects of coping strategies in rescue workers, (F) the direct and indirect causes of and risk factors for PTSD and major depressive disorder (MDD) using structural equation modeling, and (G) various other topics. Table 1 1,3e5,7,15e21,23e25,27,29,30,36e38,42e53 summarizes the research articles on the Chi-Chi Earthquake and the Morakot Typhoon related to psychiatry.

Reconstruction of life after a disaster can be a challenging process. Mental rehabilitation is a part of life reconstruction and requires a planned, comprehensive approach. Several years after the impact of the disaster, the prevalence of most psychiatric disorders will decline; however, rates of substance abuse and suicide have been shown to increase. 9,24 Mental rehabilitation is not only important as a short-term intervention, but also as a long-term follow-up mechanism. It can also prove useful in identifying cases that should be referred for further psychiatric management. Hobfoll's Conservation of Resources (COR) model has been well substantiated by previous studies on natural disasters. 39 According to Hobfoll's COR stress theory, 4,40 resource loss is an important determinant of individual stress, physical and mental health, and vulnerability to developing PTSD. Brewin et al 41 also found that although the effect sizes of all risk factors were modest, factors operating during or after the trauma such as trauma severity, lack of social support, and additional life stress, had somewhat stronger effects than did pretrauma factors.

Multiple risk factors may combine to result in psychiatric illness. According to Hobfoll's COR theory, resource loss is an important determinant of individual stress and physical and mental health, including PTSD. Our hypothesis states that an individual reaches a subthreshold of psychiatric illness and then develops the illness due to a decreasing availability of resources, an accumulation of risk factors, and/or a major stressful event. Furthermore, unresolved, subclinical psychiatric symptoms caused by a disaster or major life event may increase a survivor's sensitivity to future stresses. When faced with either stressful life events or trauma such as brain damage or deprivation of internal or external resources, individuals may become more vulnerable to psychiatric impairment and disorders such as PTSD. Our hypothesis states that an individual might reach a subthreshold for PTSD and then develop the illness due to a decreased availability of resources, an accumulation of risk factors such as personality traits or poor social interactions, or a major stressful life event. Furthermore, unresolved subclinical psychiatric symptoms caused by a disaster may increase a survivor's sensitivity to future stressors. 7 

Although the types of disasters faced in modern times may vary, it is vital to train a sufficient number of specialists and to develop a standard operating procedure (SOP) for reducing unfavorable conditions when a disaster occurs. 7 Su et al 7 endeavored to establish an SOP based on experience with mental rehabilitation efforts following the Chi-Chi Earthquake. They demonstrated that an Emergency Operation Center (EOC) should be set up as quickly as possible, generally within 1e8 h. The EOC should provide the central government with updates on the situation, as the scale of the EOC will depend on the degree of the emergency. Within 24e48 h, the EOC should assess the actual damage and coordinate "battle resources" such as manpower and equipment with the supporting teams in order to serve the real needs in the disaster area. Multiple rescue teams, including the administrative team, the public health and medical teams, and the engineering and rescueworker teams, should be involved during the urgent initial stages. An emergency management system should be established to effectively intervene immediately after a disaster. Systematic mental rehabilitation should then be performed 1e3 months after the disaster.

Su et al 7 offered a 14-part draft of potential clinical guidelines. The Taiwanese Department of Health also endeavored to publish a postdisaster mental rehabilitation book. Expert consensus concludes that every mental health rescue worker should receive 24 h of training on various topics, including: (1) the service concept of post-disaster mental health; (2) administration and procedure: (a) linkage of post-disaster service and resource offers, (b) sensitivity to culture and religion; (3) intervention of post-disaster mental health service, include mental rescue lessons, high-risk group screening and suicide prevention as well as group therapy; and (4) clinical practice.

The frequency of disasters in modern times has highlighted the value of disaster psychiatry and the importance of mental rehabilitation. It is necessary to strengthen professional awareness regarding the treatment of posttraumatic stress disorder, depression, and panic disorder. A two-stage rapid screening strategy may also prove effective, despite the typical limitations on resources following a disaster. In a two-stage survey method, the initial questionnaire can help identify high-risk groups and keep track of these individuals for mental rehabilitation, 37 which can be an effective labor-saving method. It is also vital to train a sufficient number of specialists on the guidelines for clinical intervention and to create an SOP for mitigating traumatic conditions when any disaster occurs. 

Natural disaster and mental health in Asia

The comparison of prevalence of posttraumatic stress symptoms between post-Chi-Chi earthquake survivors and post-Morakot flood survivors

Survey of psychiatric disorders in a Taiwan village population six months after a major earthquake

Epidemiologic psychiatric studies on post-disaster impact among Chi-Chi earthquake survivors in Yu-Chi

A three-year, follow-up study of the psychosocial predictors of delayed and unresolved PTSD in Taiwan Chi-Chi earthquake survivors

Post-traumatic stress disorder following disasters: a systematic review

The establishment of a standard operation procedure for psychiatric service after an earthquake

Natural and man-made disasters: the vulnerability of women-headed households and children without families

College of Public Health

Psychological impairment in the wake of disaster: the disaster-psychopathology relationship

Prevalence of psychiatric disorders among subjects exposed to a natural disaster

Prospective study of posttraumatic stress, anxiety, and depressive reactions after earthquake and political violence

Chronic posttraumatic stress disorder and diagnostic comorbidity in a disaster sample

Multiple diagnoses in posttraumatic stress disorder in the victims of a natural disaster

Quality of life and related risk factors in a Taiwanese village population 21 months after an earthquake

The relationship between quality of life and psychiatric impairment for a Taiwanese community post earthquake

Psychiatric morbidity and post-traumatic symptoms among survivors in the early stage following the 1999 earthquake in Taiwan

Psychiatric morbidity and pregnancy outcome in a disaster area of Taiwan 921 earthquake

Full and partial PTSD among earthquake survivors in rural Taiwan

Posttraumatic stress disorder among adolescent earthquake victims in Taiwan

Prevalence of psychiatric disorders among bereaved survivors of a disastrous earthquake in Taiwan

An epidemiologic study of posttraumatic stress disorder in flood victims in Hunan China

Three-year follow-up study on the relationship between posttraumatic stress symptoms and quality of life among earthquake survivors in Yu-Chi

Survey of quality of life and related risk factors for a Taiwanese village population 3 years post-earthquake

Psychiatric morbidity and posttraumatic symptoms among earthquake victims in primary care clinics

Longitudinal study of earthquake-related PTSD in a randomly selected community sample in north China

Modification effects of coping on post-traumatic morbidity among earthquake rescuers

Association of psychological distress with psychological factors in rescue workers within two months after a major earthquake

The impact of the 9-21 earthquake experiences of Taiwanese nurses as rescuers

Characteristics of acute stress symptoms and nitric oxide concentration in young rescue workers in Taiwan

Psychological consequences of the 1999 earthquake in Turkey

A mental health relief programme in Armenia after the 1988 earthquake: implementation and clinical observations

Delayed-onset posttraumatic stress disorder: a systematic review of the evidence

Traumatic events and posttraumatic stress disorder in an urban population of young adults

Psychosocial sequlae of the 1989 Newcastle earthquake: I. Community disaster experiences and psychological morbidity 6 months post-disaster

Posttraumatic distress and coping strategies among rescue workers after an earthquake

Establishment of a disaster-related psychological screening test

Workers' stress after HanshineAwaji earthquake in 1995dsymptoms related to stress after 18 months

Personal resources, coping selfefficacy, and quake exposure as predictors of psychological distress following the 1999 earthquake in Turkey

Conservation of Resources: a new attempt at conceptualizing stress

Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults

The Chinese version of the Davidson Trauma Scale: a practice test for validation

The impact of the Chi-Chi earthquake on quality of life among elderly survivors in Taiwan: a before and after study

Posttraumatic stress disorder among professional and non-professional rescuers involved in an earthquake in Taiwan

Suicide trends following the Taiwan earthquake of 1999: empirical evidence and policy implications

Before and after the 1999 Chi-Chi earthquake: traumatic events and depressive symptoms in an older population

Longterm psychological outcome of 1999 Taiwan earthquake survivors: a survey of a high-risk sample with property damage