Disaster Psychiatry in Taiwan A Comprehensive Review

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REVIEW ARTICLE

Disaster Psychiatry in Taiwan: A Comprehensive Review

Huei-Wen Angela Lo

1 , Chao-Yueh Su

2 , Frank Huang-Chih Chou

3

,

4 *

1_{Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan}

2_{Department of Nursing, I-Shiou University, Kaohsiung City, Taiwan} 3_{Kai-Suan Psychiatric Hospital, Kaohsiung City, Taiwan}

4_{Meiho University, Pingtong County, Taiwan}

a r t i c l e i n f o

Article history: Received: Dec 14, 2011 Revised: Jan 16, 2012 Accepted: Jan 18, 2012 KEY WORDS: disaster medicine; mental rehabilitation;

posttraumatic stress disorder (PTSD); the Chi-Chi Earthquake;

the Morakot Typhoon

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.

1. Introduction

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 traf

ﬁc

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

large-scale 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

2. The classi

ﬁcation of disaster

Neria et al classi

ﬁed 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., traf

ﬁc 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

cata-strophic 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

* Corresponding author. Frank Huang-Chih Chou, Kai-Suan Psychiatric Hospital, 130, Kai-Suan Second Road, Lingya District, Kaohsiung City 802, Taiwan.

E-mail: Frank Huang-Chih Chou <f50911.tw@yahoo.com.tw>

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3. The relationship between psychiatric disorders and

disaster

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 bene

ﬁt from mental rehabilitation.

7,27e30

4. PTSD in disaster survivors

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).

5. The prevalence of PTSD in disaster survivors

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

depres-sive 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.

7. The theory of mental rehabilitation post-disaster

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

Conser-vation 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

pre-trauma 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

survi-vor

’s sensitivity to future stressors.

7

8. The establishment of a standard operating procedure

Although the types of disasters faced in modern times may vary, it

is vital to train a suf

ﬁcient 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

estab-lish 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

rescue-worker 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.

9. Clinical guidelines for post-disaster mental rehabilitation

in Taiwan

Su et al

7

offered a 14-part draft of potential clinical guidelines. The

Taiwanese Department of Health also endeavored to publish a

post-disaster 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

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Table 1 Summary of psychiatric articles related to the Chi-Chi earthquake or the Morakot typhoon (PubMed search, Jan 2001eNov 2011) Author(s) Year Study period

after earthquake

Subjects Purpose Method

Chen et al17 ₂₀₀₁ _{Within 1 mo} _{525 residents} _{Screening for psychiatric morbidity and posttraumatic symptoms}

among survivors in the early stages

Purposeful sampling Chen et al42 ₂₀₀₁ _{Within 2 y} _{210 residents} _{The Chinese version of the Davidson Trauma Scale, a preliminary}

study for validation

Translation, back-translation, and concurrent validity Chang et al18 ₂₀₀₂ _{6 mo later} _{171 pregnant residents} _{Psychiatric morbidity and pregnancy outcome in a disaster area} _{Purposeful sampling}

Hsu et al20 ₂₀₀₂ _{6 wk later} _{323 student residents} _{PTSD among adolescent earthquake victims in Taiwan} _{Purposeful sampling}

Liao et al28 ₂₀₀₂ _{2 mo later} _{1104 rescue workers}

serving in the area hit by the earthquake

Association of psychological distress with psychological factors in rescue workers

Purposeful sampling

Lin et al43 ₂₀₀₂ _{1 y later} _{368 residents (268}

residentsS65 y old)

Geriatric survivors Purposeful sampling

Shih et al29 ₂₀₀₂ _{Within 1 y} _{46 nurses who worked}

in a hospital in the community

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

Purposeful sampling

Yeh et al30 ₂₀₀₂ _{Within 16 d} _{187 young, male}

military personnel who served as rescue workers

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

Purposeful sampling

Chang et al36 ₂₀₀₃ _{5 mo later} _{84 male}_{ﬁreﬁghters} _{Posttraumatic distress and coping strategies among rescue workers} _{Purposeful sampling}

Chou et al37 ₂₀₀₃ _{21 mo later} _{461 residents} _{Establishment of a disaster-related psychological screening test} _{Population survey}

Kuo et al21 ₂₀₀₃ _{2 mo later} _{120 bereaved survivors} _{Prevalence of psychiatric disorders and risk factors for PTSD and major}

depressive disorder among bereaved survivors

Purposeful sampling Yang et al25 ₂₀₀₃ _{3 mo later} _{663 victims} _{Psychiatric morbidity and posttraumatic symptoms among earthquake}

victims in primary care clinics

Purposeful sampling Chou et al15 _2004a _{21e24 mo} _{461 residents} _{Quality of life and related risk factors in Taiwanese earthquake survivors}

with different psychiatric disorders

Purposeful sampling Chou et al16 _2004b _{4e6 mo} _{4223 residents} _{Relationship between quality of life and psychiatric impairment} _{Purposeful sampling}

Guo et al44 ₂₀₀₄ _{1 mo} _{252 rescue workers} _{Prevalence of PTSD among professional and nonprofessional rescue}

workers involved in the 1999 Chi-Chi earthquake

Purposeful sampling Lai et al19 ₂₀₀₄ _{10 mo} _{252 residents} _{Full and partial PTSD among earthquake survivors in rural Taiwan} _{Random selection from}

two rural communities Chou et al3 ₂₀₀₅ _{4e6 mo} _{442 residents} _{Development of psychiatric disorders among residents post-earthquake} _{Population survey}

Yang et al45 ₂₀₀₅ _{During a 7-y}

period

d Time-related trends of increased suicide rates Time-series analysis Seplaki

et al46 2006 Before and after_{the earthquake} 1160 older individuals Variability in resilience to depressive symptoms in the aftermath of_{the 1999 earthquake} Longitudinal survey with_interviews

Wu et al24 ₂₀₀₆ _{33e36 mo} _{405 residents} _{Quality of life and related risk factors in earthquake survivors}

diagnosed with different psychiatric disorders

Population survey Chen et al47 ₂₀₀₇ _{2 y later} _{6412 earthquake}

survivors whose houses were destroyed

Prevalence and risk factors of posttraumatic stress symptoms and psychiatric morbidity

Purposeful sampling

Chou et al4 ₂₀₀₇ _{6 mo, 2 y, and}

3 y laterdtotal three times

442, 461, and 405 residents

Dynamic population survey for t risk factors for PTSD and major depression; prevalence of different psychiatric disorders 6 mo, 2 y, and 3 y after the earthquake

Population survey

Kuo et al48 ₂₀₀₇ _{1 y later} _{272 victims from}

temporary housing units

Incidence of PTSD among and the psychological health status of earthquake victims 1 y after the event

Purposeful sampling

Tsai et al23 ₂₀₀₇ _{3 y later} _{1756 respondents} _{Prospective evaluation of the relationship between the clinical course}

of posttraumatic stress symptoms and quality of life

Fixed cohort follow-up Chang et al27 ₂₀₀₈

d 193firefighters Modification effects of coping strategies on the relationship between rescue effort and psychiatric morbidity in earthquake rescue workers

Purposeful sampling Wu et al49 ₂₀₀₉

d 705 adolescent (Chi-Chi earthquake)

Examination of two models: (1) traditional social support

(2) supportive and detrimental social relations model

Using structural equation modeling (SEM) Su et al5 ₂₀₁₀ _{3 y later} _{1756 respondents}

(post-Chi-Chi earthquake)

Predicting the longitudinal course of PTSD in survivors 3 y following a catastrophic earthquake using multivariate data presented 6 mo after the earthquake

Population-based survey

Tang et al50 ₂₀₁₀ _{3 mo later} _{271 adolescents} _{Direct and indirect causes of PTSD, MDD, and risk factors using a SEM}

model (Morakot typhoon)

SEM

Yen et al51 ₂₀₁₁ _{271 adolescents} _MASC-T _{To construct validity of}

MASC-T Chinese version Yang et al52 ₂₀₁₁ _{3 mo later} _{271 adolescents}

(post-Morakot typhoon) school-based survey

Prevalence rates of PTSD, its associated factors and co-occurring psychological problems

Cluster sampling

Su et al7 ₂₀₁₁ _{3 y later} _{4223 post-Chi-Chi}

earthquake respondents

Designing a standard operating procedure for psychiatric service Population survey

Chen et al53 ₂₀₁₁ _{1 y later} _{120 Taiwanese}

aboriginal people aged S55 y old

Risk factors associated with PTSD symptoms in a middle- and old-age population who experienced Typhoon Morakot

Purposeful sampling

Modiﬁed and updated from Chou et al4_{and Su et al}7_{with permission.}

MASC-T¼ Chinese version of the Multidimensional Anxiety Scale for Children; MDD ¼ major depressive disorder; PTSD ¼ posttraumatic stress disorder; SEM ¼ structural equation modeling.

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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.

10. Conclusion

The frequency of disasters in modern times has highlighted the

value of disaster psychiatry and the importance of mental

reha-bilitation. It is necessary to strengthen professional awareness

regarding the treatment of posttraumatic stress disorder,

depres-sion, 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 suf

ﬁcient

number of specialists on the guidelines for clinical intervention and

to create an SOP for mitigating traumatic conditions when any

disaster occurs.

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