Lessons from previous incidents suggest that preparation for and response to communities' mental and psychosocial needs after a disaster require awareness of the expected behavioral health effects, understanding of the population at risk, knowledge of existing community support services, and channels for coordinating expertise among nonprofit, academic, clinical, and government institutions at the local, state, and national levels. Given the current profound environmental and economic disruption in the Gulf region, the potential effects on behavioral health include increased rates of mood, anxiety, and substance-use disorders; exacerbation of existing mental illnesses; increased rates of somatic manifestations of stress; and increased rates of child abuse and intimate-partner violence.4 Information about the population at risk may be derived in part from traditional data sources, such as the census, but more complete information requires access to local knowledge, particularly from organizations that work with historically marginalized populations. In addition, key local informants can impart crucial information about existing community services, permitting coordination among local, state, and national organizations.
Disaster response must build on the framework of existing systems. Five years after Katrina, the infrastructure for mental health and substance-abuse services in the Gulf region has evolved, but substantial challenges remain. Assets include programs, such as Reach NOLA, that train community mental health workers, using models for community engagement and peer-to-peer support. Safety-net providers have developed mobile medical units, with increasing colocation of mental and general health services. And since Katrina, grassroots organizations have empowered communities that are increasingly savvy about relevant research, disasters, and bureaucracy.
Governments' public health preparedness has also advanced considerably. Public health surveillance systems fortified during the 2009 response to the H1N1 influenza epidemic began collecting oil-related health information soon after the explosion; public health officials are exploring the use of similar methods for mental health surveillance. Through established relationships with the Centers for Disease Control and Prevention and the Substance Abuse and Mental Health Services Administration (SAMHSA), state health departments have coordinated local public health and behavioral health responses in consultation with national public health experts.
Still, we are not where we need to be. There are too few providers of mental health and substance-abuse services and too many barriers to care. Safety-net services are located predominantly in large cities, rather than coastal towns, and much of the affected area is medically underserved. In smaller communities, services are scarce for immigrants such as Vietnamese-American fishing families. Deep-seated negative public perceptions and discrimination against people with mental illnesses or addictions, compounded by suspicion of government and research institutions, make it challenging to get people in emotional distress — including health care providers — to seek or accept interventions. And there is little generalizable research on ways of reducing long-term mental health effects and rates of substance abuse after a disaster.
To enable quicker response and recovery, surveillance systems for mental illness and substance abuse must be strengthened through broader intellectual investment in a conceptual framework and technical requirements.5 Some current surveillance approaches, such as tracking calls to poison-control centers and domestic-violence hotlines, are already being applied. Other methods, such as syndromic surveillance, require refinement, given the varied somatic manifestations of stress and the potential reluctance of historically marginalized populations to seek mental health or substance-abuse services. Again, local engagement is key: community agencies can alert public health officials to emerging issues.
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