Shekhar Saxena, M.D.: Building sustainable mental health capacity before
a disaster hits may be less dramatic but more effective. Ellen
The India Ocean tsunami last December provided a tragic but much-needed
reminder that meeting the mental health needs of disaster victims takes more
than sending in planeloads of psychiatrists and mental health professionals to
debrief the victims.
"Foreigners came to help, but they didn't know the languages,"
said Shekhar Saxena, M.D., coordinator of mental health evidence and research
at the World Health Organization (WHO) in Geneva, speaking at a special
symposium during the APA annual meeting in Atlanta in May. Those language
barriers seriously limited the care the volunteers could provide, he said.
While WHO had published several reports on dealing with the mental health
outcomes of natural or man-made disasters, the tsunami only reinforced
Saxena's view that the short-term visits by foreign personnel so beloved by
the TV cameras don't do much good.
Saxena acknowledged the good intentions of Western medical groups and
individuals but suggested a number of ways they can help in emergencies aside
from their direct presence at the scene.
When disaster strikes, he said in an interview with Psychiatric
News, they should assist and support members of their profession who are
based within the disaster area. To overcome language barriers, they can also
identify fellow professionals who come from affected countries and cultures
but who are currently based in the West and financially support their longer
visits—several months or more—to the disaster area for training or
service. Professional groups can also provide material, medicines, and
equipment at the request of local societies and with local government
Longer-term, less-glamorous efforts undertaken long before disaster strikes
are more likely to help large numbers of people when the terrible day
After the tsunami struck, Saxena spent much time in Sri Lanka, a country
with just 35 psychiatrists, he said. To fill the immediate need and provide a
quick response to survivors, WHO gave social service training to local
authorities such as teachers, police, and postal workers.
WHO urged Sri Lanka, India, Indonesia, and other countries affected to give
more thought-out responses to offers of aid, which poured in last
"Not just `yes,' but also `yes, but'; `not now'; or `what about this
kind of help instead of that one?'" are examples of such responses,
Building sustainable mental health capacity before disaster hits may be
less dramatic but more effective, he said. The early preparation should
include training local medical personnel in "basic, general mental
health care and psychological first aid," then drawing up plans for a
mental health response to future disasters.
"At times of crisis, don't think only about professionals,"
said Srinivasi Murthy, M.D., also of WHO, at the Atlanta meeting."
Interventions should focus on increasing individual resiliency,
improving community cohesion, and integrating mental health care with schools
and other institutions."
Feelings of distress and psychiatric disorders both rise after a disaster,
then decline, although not to baseline levels, he said. Nevertheless, the
immediate needs are largely practical.
"A fisherman needs a new net, not more mental health services,"
said Frank Njenga, M.D., of Kenya, a former president of the African
Many in the developing world see the posttraumatic stress disorder (PTSD)
model as a Western phenomenon, one not widely applicable elsewhere.
The interventions often employed to reduce traumatic stress, like one-time
psychological debriefings or benzodiazepine medications, show little evidence
of effectiveness, and using them indiscriminately can even be harmful, wrote
Saxena and two WHO colleagues, Mark van Ommeren, Ph.D., and Benedetto
Saraceno, M.D., in the January Bulletin of the World Health
Immediately following an event, people need a flow of accurate information
and a return to normal activities and community participation, said the WHO
team. Facts about the emergency, relief efforts or organizations, and help in
locating families can reduce public anxiety and distress. Restarting schooling
and recreational activities can recreate a semblance of normal life for
children. Cultural and religious practices, including funerals and mourning
rituals, should be encouraged, as should recruiting adults and adolescents for
communal activities such as reconstruction efforts.
"We must look beyond our ethnocentric bias and consider not just
PTSD, but PTG—posttraumatic growth," added Lennart Levi, M.D.,
Ph.D., former director of the Division of Stress Research at the Karolinska
Institute in Stockholm, Sweden.
Most persons with urgent psychiatric problems will have pre-existing
disorders such as psychoses or severe depression, said van Ommeren, Saxena,
and Saraceno. Those patients should be managed with appropriate
More common acute-stress problems occasioned by the disaster can be treated
with psychological first aid: caring for basic needs, protecting survivors
from further harm, offering nonintrusive emotional support, and organizing
social supports. "Teach the population that their emotional reactions to
disaster are normal and tailor responses to local situations," said
The WHO report discourages blanket use of isolated psychological debriefing
sessions that push people to share their experiences beyond their personal or
cultural inclinations. Instead, in the postemergency phase, mental health
services, including trauma-related care, should be integrated into the general
health care system. Many well-meaning foreign health personnel leave too
early, said several speakers.
"At present, nongovernmental organizations fuelled by donor
enthusiasm rush in to debrief trauma survivors in the early phase
when such interventions are not needed and commonly leave just at the point
when the more chronic cases emerge," wrote Derrick Silove, M.D., a
professor of psychiatry at the University of New South Wales, Australia, in an
accompanying commentary in the WHO Bulletin.
Long-term solutions are the answer, Saxena said at the Atlanta meeting."
We must empower communities. At the moment, there is too little money
for sustainable action."
The WHO report, "Mental and Social Health During and After
Acute Emergencies: Emerging Consensus?," is posted online at<www.who.int/entity/bulletin/volumes/83/1/71.pdf>.▪