Key Characteristics of Behavioral Health Impacts
- There will be a continuum of behavioral health impacts and needs both in the short and long term, and thus “one size does not fit all” for individuals and communities.
- Symptoms are very common early in an incident (acute distress) and are not prognostic of poor outcomes in the long term, but they should be accounted for in planning and education.
- Disasters frequently produce a range of reactions:
- Resilience is the most common child response (45%-79%) to natural disasters6 .
- A subset of youth experience severe post-disaster behavioral health impacts6,44,45 :
- 7%-27% have an initial elevation of posttraumatic stress symptoms followed by symptom decrease.
- 8.4%-32.9% will meet criteria for Post-Traumatic Stress Disorder (PTSD) with higher rates for those who experienced acts of terrorism/intentional violence.
- Symptoms and reactions can be influenced by many factors, including but not limited to44-59 : hazard factors (timing, magnitude, type), prior experiences, prior existing distress or behavioral health disorders, sociodemographic risk factors20,44,60-81 (variable based on nature of incident), family resilience factors, severity and duration of impacts, and neurodevelopmental age.
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- A behavioral health impact assessment should be conducted early in the disaster to evaluate the anticipated scope and scale of behavioral health impacts and compare them to available community/response resources. This process is covered in the Response Implementation section of this toolkit.
- This gap analysis can be used to inform the estimated behavioral health service/support demands and appropriate strategy for the incident, which includes planning for responder and staff wellness/resilience to ensure long-term capability to conduct work.
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- Disasters also impact responders and staff, and behavioral health resilience and risks are influenced by their exposure and experiences during the incident.
- Behavioral health impacts can reduce long-term workforce capacity, particularly in prolonged and more severe incidents.
- In addition to resilience, they can experience a range of behavioral health impacts including burnout, compassion fatigue, secondary traumatic stress, Acute Stress Disorder (ASD), PTSD, and depression. Estimates for PTSD and depression can range between 25%-80% depending on specific sector of work.
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- Organizations should prepare to support responder and staff wellness/resilience to ensure sustainability, efficacy, and safety of medical and behavioral health recovery efforts.
- A comprehensive professional and personal wellness plan should be in place. This can be structured based on three levels. For example, in hospitals this would include: the individual/provider level, health system leadership level (clinical and hospital leaders), and organization level.
- Please see a Primer on Professional and Personal Wellness Considerations.
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- Disaster behavioral health needs will present differently and change over time, and thus the supports required to meet those needs will likely change.
- Behavioral health reactions to disasters have several key characteristics that influence response and recovery:
- The individual trajectory models are useful to understand how different individuals may experience impacts and their potential behavioral health needs (several models exist; Example 1, Example 2).
- The community phases model synthesizes anticipated broad community reactions with typical disaster response and recovery phases. The needs of individuals and communities should be expected to vary dramatically and there may be delays before needs arise. Repeated disasters can cause a cascade, which restarts this cycle. There are models for both a single disaster and concurrent disasters.
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- Individual and community behavioral health impacts should continually be evaluated and communicated to inform both response and community actions.
- Response and recovery initiatives should be mindful for the potential behavioral health surge after a time delay.
- Evaluation of the proper assessment/measure at an individual level, and Essential Elements of Information (EEI) at a population level, are key for proper evaluation and ongoing monitoring.
- For example:
- Individual: Psychological triage early in a disaster can provide critical insights on the potential behavioral health needs of those triaged.
- Population level: Monitoring the rates of children presenting for psychological distress in emergency departments within the 3 months post disaster can provide insight on the current level of community behavioral health needs.
- Some measures may be more valid after a period of time has passed. Suicidal ideation rates may not reflect in emergency department data for a significant period of time until after the event occurred.
- Further recommendations on assessment approaches and Essential Elements of Information are outlined in the Response Implementation section of this toolkit.
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Resource Gaps & Prioritization: Behavioral health services are chronically under-resourced in many communities and this gap will only grow (often dramatically) after a disaster.
- Prioritization of services to those most in need is critical to achieve the most benefits with the resources available.
- Availability of resources greatly varies from one community to another and from one time to another.
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- Day-to-day behavioral health system limitations and fragility will significantly influence response and recovery outcomes.
- Where possible, increasing capacity of the day-to-day continuum of care directly increases the resilience of the system and community.
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Service Continuum: Availability of a range of supports and interventions is critical to meet everyone’s needs, including both those who need limited support to maintain a positive trajectory and those who need more intensive supports.
- Given there are a range of reactions and behavioral health needs post disaster, not everyone in a community needs, or should receive, the same type and level of support.
- These needs will vary based on the disaster, type, extent and impact of exposure, and ongoing strengths and vulnerabilities of the particular community.
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- To meet a spectrum of needs, it is essential to offer both a continuum of services/supports to meet needs and to triage and prioritize access to those services based on objective risk.
- This approach should be informed by the initial impact size-up/gap analysis for the disaster and ongoing situational awareness of behavioral health impacts.
- Ideally, this will be supported by a rational and effective process to prioritize care, such as psychological triage (e.g., PsySTART). With that in mind, any process to identify acuity of needs and prioritize limited services based on that acuity will be more effective than simply providing care to those who demand it.
- Typically, this continuum involves providing population-level supports to a broad spectrum of individuals (broad + low acuity: such as psycho-social education; Psychological First Aid) and more intensive, group or individualized interventions to those at higher risk (targeted + high acuity: such as Cognitive Behavioral Intervention for Trauma in Schools and Trauma-Focused Cognitive Behavioral Therapy), with a continuum of services in between.
- The PDBH Care Guidelines outlines the considerations and broad approach to advance from initial impact evaluation, to identify potential care needs, and develop a service delivery approach.
- For a list of potential interventions, please see SAMHSA’s Disaster Behavioral Health Interventions Inventory.
- Disaster behavioral health response and recovery strategy must be adapted based on the gap between behavioral health impacts (and thus demands) and accessible behavioral health resources – which varies based on the incident and impacted community.
- The bigger the gap, the more highly specialized services must be focused on those at greatest risk (prioritization/triage). As response models increasingly rely on population-level approaches, scalable, replicable, and modular features, as well as train-the-trainer strategies, become increasingly important.
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| Intervention Timeliness: Timely intervention can influence effectiveness of various interventions to reduce the rates/likelihood of developing new and/or more severe behavioral health disorders. |
- Disaster behavioral health response must begin to organize and mobilize early in a disaster to:
- Rapidly provide support to reduce long-term behavioral health impacts (intervention timeliness).
- Develop a recovery mission and organize resources to support the expected short- and long-term behavioral health impacts.
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| Lack of Readiness: Behavioral health response and recovery is very often an underdeveloped and under-exercised function for the majority of preparedness and response entities within the U.S. |
- Preparedness for disaster behavioral health response is just as critical as it is for any other response function.
- To adequately meet disaster behavioral health needs in the response phase, it is critical that organizations implement a trauma-informed care approach in the preparedness phase.
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Integration of Behavioral Health Into Response: Behavioral health response and coordination efforts will be ineffective if they are not integrated across all response functions (general and specific) and aligned to serve both the community and the overall response effort.
- Many response functions have critical behavioral health considerations that should be implemented for success, such as isolation and quarantine, chemical – biological – radiological – and nuclear (CBRN), or family reunification.
- Medical surge must include behavioral health surge management considerations, particularly for CBRN incidents, where medically unexplained physical symptoms can significantly outnumber those physically exposed.
- Individuals may be less likely to engage with formal behavioral health response services; therefore, outreach should be adapted to meet individuals where they are to increase engagement.
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- Behavioral health must be integrated into response and functions.
- Use and/or engagement of Incident Command System (ICS)/Hospital Incident Command System (HICS) incident action planning process is an extremely effective way to facilitate this integration and is considered a response best practice.
- Engagement of formal planning structures such as internal emergency management programs or external planning groups (such as Emergency Support or Recovery Support Functions) is critical to ensure integration into broader coordination efforts, if they exist.
- This engagement should go beyond just having behavioral health be part of the response as a function.
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- This includes behavioral health having “a seat at the table,” behavioral health considerations and expertise integrated into universal and specific response functions, and responder and staff wellness components strongly supported.
- In particular, any medical surge management activities should have integration of behavioral health expertise.
- Further recommendations on this are outlined in the Response Implementation section of this toolkit.
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| Adaptation of Response to Community: Behavioral health response must adapt to the needs of the community in organization, communication, and execution or it will be ignored by the community or even actively resisted. |
- Behavioral health response should engage the community and reflect their needs, desires, and culture.
- Ideally, this is achieved through meaningful and strategic community engagement before, during, and after a disaster.
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