Mental Illness Following Disasters in Low Income Countries

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a peer reviewed article

Abstract

Disasters test the capacity of health infrastructure to act in a well-coordinated and adaptable manner, due to the unique nature of each event. While immediate provision of healthcare focuses on the physical consequences, the long term mental health ramifications of such events are often forgotten, and services are ill-equipped to deal with the mental illnesses arising from them. The inherent challenges to the public health response are compounded by the limitations experienced by Low to Middle Income Countries (LMIC). These countries may lack the fiscal resources to fund such interventions and have unstable socio-political environments, which may further complicate disaster response. It is by consideration of these limitations, risk factors specific to such countries, and cultural sensitivity then that effective, long-standing mental health interventions can be implemented. This paper will review the predisposing factors to mental illness development following disaster, particularly in respect to at-risk subpopulations, the impact of socio-political climate and low GDP on disaster response, and the development of effective, culturally-specific interventions. The intersection between low national GDP and poor mental health infrastructure often translates to poorer mental health outcomes following disaster. Women, people of low educational status and low income are especially predisposed to development of mental illness. Common mental health disorders include Post Traumatic Stress Disorder, depression and anxiety

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Introduction

In Low and Middle Income Countries (LMIC), mental health care considerations of disaster survivors have taken a proverbial back seat, as the establishment of basic needs take priority.[1] Unfortunately, overwhelming evidence of causality between natural disasters and mental health issues has confirmed that provision of culture-specific mental health care is an integral part of the public health response following massive loss of life and injury to minimise long-term recovery ramifications, and a lack of these services negatively impacts survivors.[2]

Psychosocial and mental health support programmes are increasingly being recognised as a crucial component of the humanitarian response to disasters.[3] However, disaster response coordination is notoriously complicated with numerous factors to consider, and lack of funding and resources in low income countries further limits health responses.[4] This paper will examine the predisposing factors to the development of mental illness in those affected by disaster in LMIC, and suggests potential preventative actions.

Common mental health disorders arising from disasters

Poor mental health in the immediate aftermath following disasters is to be expected in most survivors, the degree of suffering is affected by the nature of the experience, support networks, coping skills and the community response.[4] This suffering includes distress –situations in which the individual feels anger, fear, sadness or shame – emotional dysregulation, or emotional numbing, however these typically resolve without long-term consequences.[5] It is when they are sustained, and impact on daily functioning, that they are defined as a ‘mental illness’. The most common of these are the anxiety disorders, particularly Post Traumatic Stress Disorder (PTSD), in which the individual experiences heightened arousal, avoidance of triggers, and flashback episodes.[5] Other mood disorders commonly experienced include abnormal grief reactions and depression.

Due to the decreased utilisation of health services, particularly mental health services around the world and especially in Low to Middle Income Countries (LMIC), individuals may attempt to self-medicate with alcohol and other substances.[4] This may lead to substance use disorders as a way to deal with stressors, by avoiding or displacing difficult emotions associated with disasters. This is especially common in patients with a history of substance use disorder in remission, as relapse is common following stressful events.

Somatisation disorders also show increased incidence following disasters; a way for survivors to express emotional distress.[2] They are more likely to occur in individuals with other concurrent mental health diagnoses, such as PTSD. Various cultures approach emotional distress as irrational, and thus there are a number of culture-specific disorders that manifest in this way.[3] These include Latah, a condition originating in Southeast Asia in which individuals have an abnormal startle reaction; Koro, significant anxiety surrounding recession of genitalia; or Susto, a cultural variation of panic attacks originating in Latin America.[6] Knowledge and sensitivity surrounding these diagnoses may dramatically increase utilisation and efficacy of mental health programs in disaster areas.

Predisposing factors to mental health disorder diagnosis

There is a complex interplay between social dynamics and mental health diagnoses, and alteration for cultural context is an important consideration for any mental health intervention to be effective. Disasters have the potential to have a greater impact than initially considered because of the fear regarding the loss of long-held traditions that define the culture and community of those affected.[7]

Gender

Of people impacted by disaster in LMIC, females have been shown to have a higher overall likelihood of developing mental health disorders, particularly depression.[8, 9] Recognition of the specific cultural challenges that females face following a disaster may reduce the impact of events on their recovery. Females in LMIC often occupy roles of household responsibility, and women may therefore feel guilty regarding their lack of ability to tend to basic domestic tasks. Practical consideration may also mitigate some impact of the trauma; though shelters often offer gender-segregated areas, nursing mothers may be reluctant to feed in public spaces. Women may suffer additional mental strain or sexual harassment if they are obliged to use public toilet services, or if they are seen in wet clothing in traditionally modest countries. These considerations must be kept in mind for established relief facilities to be effective, particularly in the case of foreign aid provision.

Low income

The correlation between low income in LMIC and increased propensity towards poor mental health may be explained by the ‘reserve capacity model’.[5] This model states that as individuals have increasing background worries – for instance uncertainty regarding income and food shortages – their capacity to deal with additional stressors, as in the case of disaster, diminishes accordingly. It is well established that those of low Socio-Economic Status (SES) have poorer mental health, and often have the least access to services, either because lack of funding or locational difficulties.[10] Recognising low SES as a risk factor for the development of mental illness following disaster may allow more targeted relief efforts to be initiated.

Formal education

Education and financial stability may also influence recovery and disease development.[10] One of the key areas preventing development of LMIC is the lack of formal education of its citizens. This may also influence coping capacity following a disaster. On a practical level, educated individuals have an increased ability to cope with documentation demands, applications and resource seeking. This accordingly reduces the stress and impact of coping following disasters. Similarly, financial status may impact individuals at every stage of disasters. Those with lower incomes may have poorer quality of life and less safe dwellings, and are thus most predisposed to damage in the event of disasters.[11] Additionally, poor financial reserves may make it difficult to repair houses, and thus affects post-disaster recovery as well as the reserve capacity of individuals.

At-risk subpopulations

Children

Children are amongst the most vulnerable groups to disasters.[12] Negative long-term effects on paediatric wellbeing include increased incidence of PTSD, depression, and life dissatisfaction. Children may lose one or both parents due to disasters, potentially leaving them without a primary caregiver in areas with inadequate infrastructure such as education to meet their needs.

Such events have been showed to have a deleterious impact on school performance, particularly in young males.[13] In countries where education level has a direct correlation with lifetime health quality, lack of access to education may drastically alter an individual’s life course, as well as the overall poverty level of the affected country. Schools, if still operational, may provide invaluable facilities for mental health support for students following natural disaster events in LMIC. Schools provide a relatively stable environment for observation and continued support, and they may bring a sense of normalcy back to areas ravaged by disaster.[14]

Aid workers

A specific challenge is to assess and care for the first responders and aid workers who assist in relief work following a disaster. All rescue workers have a higher risk of chronic distress following exposure to an incident; although several elements, such as years of experience, perceived locus of control and social support; may mitigate development of disease.[15] These factors are important as responders are often foreign aid workers, operating without existing infrastructure and in unfamiliar environments devoid of a support network. Though they are often briefed beforehand and may receive training to prevent long-term mental health consequences, such workers are often volunteers with minimal experience. There is also some degree of stoicism amongst these volunteers, as their degree of suffering is judged to be far less than that of the people they are assisting.

Specific considerations in LMIC

The impact of disasters in LMIC appears to be far greater, in part due to the fragility of their existing infrastructure, and the lack of significant financial reserves to rebuild and support affected communities.[3] It is expected that encroaching urbanisation and industrialisation of developing counties will increase the incidence of disasters – both man-made and natural – and that developing countries will be most affected in terms of number and severity. It has been shown that the risk of PTSD also rises proportionate to increase in severity and frequency of such events.[15]

Several factors worsen the impact of disasters. Houses are often of inferior build quality, which reduces the ability to withstand severe forces.[7] Slums and communities experiencing poverty are also likely to be built in disaster-prone areas such as flood plains because their inhabitants are unable to obtain property in safer areas.

In the immediate aftermath of these events, LMIC may struggle to adequately treat the problems of their citizens due to limited training and capacity of healthcare and aid professionals.[10] The World Health Organization has recognised the role of unskilled aid workers in assessing mental health conditions and have devised a framework to use in these circumstances.[16] Untrained or poorly-organised humanitarian aid and destruction of primary infrastructure may also constitute secondary stressors following natural disasters and may compound the initial trauma of the event. Improper, or lack of, information dissemination may lead to anxiety and depression about food distribution, with negatively impacts on community wellbeing.[3]

Determinants of effectiveness of public health responses

One of the difficulties surrounding mental health disaster response is the changeable nature of the assistance required. Systems required in the immediate aftermath to aid those dealing with loss, physical impairment and adaptation to a different way of life are vastly different as some people return to their original occupations and homes.[3] Pre-disaster planning should involve a multidisciplinary team of healthcare professionals, infrastructure experts and politicians to create lasting policies that are effective and easily implemented.

Disparities in the availability, accessibility and quality of mental healthcare due to ethnicity are well-documented. This may be due to language barriers, fears regarding insurance and monetary constraints, geographical difficulties (especially in rural communities), mental health stigma and lack of education.[7] Addressing these barriers may increase uptake of such services and reduce the incidence of mental health-related decrease in quality of life for those most at risk.

Solutions include the validation and normalisation of distress reactions, so individuals feel they are experiencing legitimate reactions, rather than moments of weakness.[7] It is important to recognise the role of communities and to establish programs which value interdependence rather than independence in such situations. Promoting community action and initiatives will increase community resilience and realisation of the true impact of shared events.

Cultural competence and sensitivity in foreign aid workers is essential to effective integration of support services, as well as the recognition that cultural competence is an ongoing learning process rather than an end-state.[16] It is important to identify the causes of potential stigma and mistrust in order to properly engage minorities in healthcare. Rituals and traditions from the cultures of those affected may also be utilised and integrated into care solutions, thus using innovative interventions to circumvent such difficulties. Finally, it is critical that aid workers and all stakeholders advocate, facilitate and conduct research into the incidence of mental illness and effective treatment solutions for mental illness in affected populations to increase efficacy of interventions in the future.[1]

Disaster-derived mental illness: a contemporary perspective

Disasters today are often man-made, as in the case of conflict. There is scarce research into the impact of such political conflict in LMIC. Of the research exists, it has been shown that women and people with a past history of mental illness have the greatest risk of developing mental disorders post-event.[17] Higher levels of constant political terror – measured on a scale that stratified countries according to the frequency of politically-motivated crises – directly correlated with higher rates of PTSD and depression.[18] Resource limitation directly impacts on the quality and quantity of care provided because LMIC must allocate fiscal resources frugally. They often chose to apportion money only to the most severely-affected populations, where the greatest benefit would be attained. This, in addition to the deterioration of healthcare services in wartime, culminates in a dearth of services for all but the most severely affected.

The current global political climate, with the rise of nationalism and the unprecedented numbers of people displaced by conflict worldwide, also raise a number of considerations with respect to disaster preparedness.[19] There are more people displaced by conflict than ever before, seeking relocation in countries with greater stability and economic opportunity. The mental health of refugees is also influenced by the circumstances in the country of their resettlement. For example, a study of Latino and Asian refugees arriving in America found that those who experienced discrimination, unemployment or who experienced uncertainty due to unpredictable health insurance had lower self-rated mental health.[19] These post-settlement factors had a greater impact on their mental health than pre-settlement trauma, including war-related trauma.[19] This reflects the detrimental effect of hostile attitudes from the host country towards displaced individuals, and should be considered in the provision of mental health services for these affected communities.

The impact of political instability on disaster responses in LMIC was also demonstrated following the earthquake in Nepal’s Gorkha region. Nepal has a GDP of only $20 billion USD, and an extremely limited capacity to fund disaster relief operations. Political instability and slow constitutional development following abolition of the region’s monarchy has prevented ratification of rigorous governance surrounding disaster prevention efforts, such as building codes, which may have reduced the impact of such an event.

Conclusion

Considerations regarding the provision of mental health support to people in LMIC following disasters rely on a complex interplay between existing culture, socio-political climate and financial constraints hindering relief and prevention efforts. This review has identified that potential avenues for improvement of mental health services in disaster responses include: identification of most at-risk subpopulations including low SES; active integration of cultural sensitivity in in the provision of mental health support; and measures to address barriers in uptake of care. Though further research is needed into the impacts of disaster in LMIC, governments must actively engage in policy development before these events occur and learn from previous experiences to protect their citizens from long-term mental health implications of disasters.

Rose Brazilek

Rose Brazilek is a PhD candidate studying through the Australian Centre for Blood Disease at the Alfred Hospital. She has a keen interest in translational medical research and blood disorders. In the future, she hopes to specialise in haematology with a special interest in thrombosis and haemostasis.

Acknowledgements

None

Conflict of Interest

None declared

Correspondence

rose.brazilek1@monash.edu

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