Earthquakes are natural disasters that significantly impact individuals living in affected communities. Depending on the intensity and magnitude, the consequences of an earthquake might be devastating and may cause significant mental health problems,Reference Wu, Xu and He 1 including reaction to severe stress and adjustment disorders (RSSAD).
On September 19, 1985, Mexico was struck by one of the most severe earthquakes of its history (7.8 short waves magnitude; 8.1 long waves magnitude),Reference Bitrán 2 which was followed the next day by a second earthquake (7.3 magnitude). Both caused thousands of people to lose their lives, their homes, and their jobs.
Mental health care interventions from the Ministry of Health soon started and affected people housed in shelters located in the metropolitan area of Mexico City.Reference De la Fuente 3 Twenty-eight percent of affected individuals reported posttraumatic stress disorder (PTSD). In a later study by the Mexican Institute of Psychiatry, the prevalence of PTSD was 32%.Reference Tapia-Conyer, Sepúlveda-Amor and Medina-Mora 4
On September 7, 2017, an earthquake of 8.2 degrees on the Richter scale occurred, 5 with severe effects in Oaxaca, Chiapas, and Tabasco states. A few days afterward, a new devastating earthquake (7.1 on the Richter scale) occurred on September 19, generating more than 360 deaths and tens of thousands of victims in Mexico City and other states of Mexico. This event occurred exactly 32 years after the 1985 earthquake, only a few hours later after millions of Mexicans carried out evacuation drills.Reference Hernández and Téllez 6
On September 23, a new earthquake with an intensity of 6.1 degrees on the Richter scale occurred, 5 activating seismic alerts and fear reactions in millions of Mexicans. No severe damage to buildings was registered, but at least 2 women died from heart attacks. 7 After such a life-threatening experience, it is expected that admissions to psychiatric emergency services increase as has been previously reported in disasters, such as Hurricane Katrina in the United States,Reference Galea, Brewin and Gruber 8 , Reference Kessler, Galea, Jones and Parker 9 the tsunami in Thailand,Reference van Griensven, Chakkraband and Thienkrua 10 and the Great East Japan earthquake.Reference Sakuma, Ueda and Rengi 11 To our knowledge, there is no study that has examined the increase in the number of psychiatric consultations after a natural disaster, neither if RSSAD are more prominent in these consultations.
METHODS
The present study was carried out between September and November of 2017 in the Continuous Psychiatric Care (CPC) Department (area of attention to psychiatric emergencies) of the National Institute of Psychiatry Ramon de la Fuente, a highly specialized mental health center in Mexico City.
Participants
The present study was a retrospective review of a database from all individuals who voluntarily asked for an emergency consultation from September 1 to November 30, 2017. All users signed an informed consent that authorized a voluntary consultation and the anonymous use of clinical data for bio-statistical purposes. The review was approved by the Hospital Disaster and Safety Institutional Committees.
Assessments
The Color-Risk Psychiatric Triage (CRPT) assessmentReference Molina-López, Cruz-Islas and Palma-Cortés 12 was performed as soon as the individual arrived to the CPC Department – information about age, sex, and diagnosis of individuals according to the 10th version of the International Classification of Diseases (ICD-10). 13
Statistical Analysis
All analyses were performed using the version 22.0 of the SPSS software. Bivariate analyses for comparisons of variables between the months of assessments were carried out using chi-square tests (χ2) for categorical variables, and one-way ANOVA followed by Bonferroni tests were used for continuous variables.
RESULTS
A total of 1,811 psychiatric emergency consultations were registered from September 1 to November 30, 2017. More than half of the consultations were for women (67.1%, n = 1,216), and the mean age was 36.6 years (SD = 15.9, range 11–96).
A total of 141 consultations were of patients with diagnoses of RSSAD, mainly acute stress reaction (ASR, 68.1%; n = 96), PTSD (15.6%, n = 22), adjustment disorders (14.9%, n = 21), and other reactions to severe stress (1.4%, n = 2). The mean age of the patients with these diagnoses was 38.5 years (SD = 15.1, range 13-83), and women accounted for 82.3% (n = 116) of these consultations.
A significant increase of consultations was observed after September 23, with a progressive decrease in RSSAD consultations until November (Figure 1). The majority of the RSSAD consultations were for ASR (74.0%, n = 57 for September and 66.7%, n = 36 for October), which decreased to 30.0% (n = 3) in November, where 50.0% (n = 5) of the consultations were for PTSD (χ2 = 14.3, P = 0.02).
Distribution of the RSSAD Consultations in the CPC Department from September to November 2017.
Sex, age, shift of attendance, type, and duration of consultation of RSSAD patients were similar between the days of September before the earthquakes. The CRPT assessment of the urgency of the psychiatric emergency consultation is also displayed in Table 1. Before the earthquakes, three-quarters of the RSSAD consultations were classified as green (mild risk presentation); for the remaining days of September, more than 60% of the consultations were classified as yellow (middle risk presentation), χ2 = 21.4, P = 0.006.
Demographic Features and Characteristics of RSSAD Consultations From September to November 2017
CRPT = Color-Risk Psychiatric Triage assessment.
DISCUSSION
Although it was previously reported that some natural disasters can trigger diverse RSSAD that leads victims to seek for medical or psychiatric attention,Reference Cassachia, Bianchini and Mazza 14 to our knowledge, this is the first study that reports a specific change of activity indicators in a Mexican psychiatric emergency department due to significant disasters such as the earthquakes of September 2017.
The first and most noticeable outcome was the increase of demand of the CPC Department related to RSSAD, which was far more pronounced after the second earthquake (September 23). This significant increase could be explained because induced re-experience can lead to arousal in an acute stress disorder.Reference Nixon and Bryant 15
Previous to the earthquakes, from 2004 to 2008, the RSSAD conditions represented less than 2% of overall census activity of the CPC Department.Reference Molina, Lopez-Pedraza and Morales-Gordillo 16 After the earthquakes, RSSAD conditions modified the baseline indicators and might have lead to some undesirable outcomes like an increase in waiting times, and a negative perception of safety and quality of attention in health care providers may be present.Reference Eriksson, Gellerstedt, Hilleras and Craftman 17
Our results are in accordance with some previous studies that have reported significant enhancing in census activity of emergency departments of local general hospitals after a natural disaster had occurred. Aitken et al.Reference Aitken, Franklin and Lawlor 18 found a significant increase in emergency consultations after Tropical Cyclone Yasi struck Australia on February 2011. Other studies have found significant people affected with RSSAD,Reference Farooqui, Quadri and Suriya 19 , Reference Neria, Nandi and Galea 20 but most of this information came from interviews not performed in a psychiatric emergency department.
This study had several limitations. First, our sample was from a census activity of a psychiatric emergency department, which is not a probabilistic sample, and therefore it cannot be representative of the Mexican population. Second, we studied RSSAD as a retrospective diagnosis, and it is important to differentiate prospectively, whereas the main clinical feature was ASR or PTSD.
Despite these caveats, our study adds empirical evidence that might contribute to the understanding of the way in which the demand for services in emergency units behaves in this type of health emergencies, and then to the planning of efficient responses to future similar events. Mental health professionals must be adequately trained and sensitized about disaster victims and the physical and mental responses to disasters.Reference Botha Pedersen, Gjerlan and Rund 21 Some authors have recommended the improvement of ergonomic conditions, building trustful relationships with management and within the health teams, and strategies to reduce possible work-life conflicts in order to have better outcomes as mental health providers.Reference Cetrano, Tedeschi and Rabbi 22
These efforts to care for the mental health of people suffering before a natural disaster and their helpers seem to be necessary in the long term. A couple of months had passed after these earthquakes, and we cannot ignore that these earthquakes, as well as the one lived through in 1985, brought out a real humanitarian response by thousands of Mexicans. Fear, tiredness, and grief were not barriers if there was another Mexican peer in disgrace. Colleagues might call it resilience, but we may also call it simple fraternity. Ideally, this other type of helpers should receive at least a communitarian mental health intervention in return.
CONCLUSION
A natural disaster, such as an earthquake, impacts the person who lives it in terms of safety, physical integrity, and emotional and mental stability. The attention and monitoring of mental health after a natural disaster is a priority to avoid future complications associated with the presence of RSSAD that would negatively affect the quality of life of the people affected.
