Natural disasters by their very nature occur suddenly and have the potential to cause great harm at an individual, family, community, and societal level. They occur frequently, and with the escalation in extreme events related to climate change, the frequency, and severity of natural disasters will only increase (Intergovernmental Panel on Climate Change (IPCC), Reference Field, Barros, Dokken, Mach, Mastrandrea, Bilir, Chatterjee, Ebi, Estrada, Genova, Girma, Kissel, Levy, MacCracken, Mastrandrea and White2014). Globally, a growing number of people are being exposed to natural disaster; however, the vulnerability to exposure is not equally shared. Those who are socially, physically, economically, culturally, politically, institutionally, or otherwise disadvantaged are especially vulnerable to experiencing natural disaster.
While the immediate health relief response after disaster usually focuses on meeting the physical needs of individuals, there is increasing awareness of the impact of disasters on mental health. People exposed to disasters commonly experience a range of stress-related emotions including disbelief, sadness, anxiety, anger, and grief. Generally these emotions dissipate over time as the process of rebuilding one's life starts to take shape and the survivor harnesses their coping strategies and supports. However, a substantial minority develop a range of mental health conditions. These may include, but not limited to, post-traumatic stress disorder (PTSD), depression, anxiety disorders, and substance use disorders. This mental health burden represents a significant cost to society in addition to the individual, their families, and their social and economic networks. Identifying the factors that contribute to psychological vulnerability is an important component of preparing for and addressing the aftermath of natural disasters.
As such Parker and colleagues’ (Reference Parker2015) examination of the mental health implications of natural disasters for older adults represents a timely contribution to the literature. Using the rigorous methodology of systematic review and random-effects meta-analysis they identified papers that examined the impact of natural disasters on the mental health and psychological distressed experienced by older adults. As part of their inclusion criteria, they required primary outcome measurement of PTSD, depression, anxiety disorders, adjustment disorder, and/or psychological distress, and they used the United Nations definition of older adults, i.e. over 60 years. A total of six papers were identified through this rigorous screening process.
Parker et al. (Reference Parker2015) found that older adults were more likely to experience PTSD symptoms after exposure to natural disasters relative to young adults (OR + 2.11, 95% CI 1.40–3.17). Similarly older adults were more likely to experience adjustment disorder after exposure (OR = 1.73, 95% CI = 1.05, 2.86). Interestingly, the authors did not find an increased risk for depression, anxiety, and psychological distress. These important findings beg the question about what increases older people's risk to poor mental health after natural disaster? It also raises questions about why the vulnerability appears more specific to PTSD compared with depression and anxiety. The authors make the important observation that baseline prevalence of PTSD in non-disaster community samples decreases after age 55 years and thus the higher rate of PTSD found in older adults following natural disaster are probably not due to higher baseline prevalence. Rather, the authors suggest that other risk factors for PTSD may particularly affect older adults. For example, female gender is associated with increased risk to PTSD and given women live longer than men the gender skew might contribute to the findings. Similarly, older persons tend to be over represented in the casualties of sudden onset natural disasters and therefore may have to contend with ongoing stressors such as pain, injury, and bereavement, which in turn contribute to PTSD or adjustment disorder vulnerability. Alternatively, we may also wonder whether greater physical vulnerability that can accompany older age increases the risks for an acute fear response to the threat of disaster, hence increasing the risk of a fear disorder such as PTSD compared with depression.
The study has a number of limitations. As is the case of all systematic reviews/meta-analyses, they are only as good as the studies that meet the inclusion criteria. The authors identified that psychosocial disaster research suffers from poor methodology, a point that was made by Norris (Reference Norris1992) who noted that the quality of the psychosocial disaster research was on the decline particularly in terms of sample size and follow-up periods. Parker and colleagues make the important point that the field requires studies that utilize standardized methodologies so that comparisons can be easily made across studies.
The question this paper leaves us with is what should be done in the aftermath of natural disaster to protect the mental health of individuals, especially those like the elderly, who may have increased vulnerability to poor mental health outcomes. Various international bodies such as the Inter-Agency Standing Committee (IASC) and the NATO Joint Medical Committee have proposed evidenced informed strategic stepped models of care (IASC, 2014; NATO, 2014). Similarly, Forbes et al. (Reference Forbes, Creamer and Wade2012) and their colleagues advocated a stratified approach when they developed and implemented a three-level framework after the 2009 Black Saturday Bushfires in Victoria, Australia. This approach to psychosocial care proposes a universal psychosocial intervention which is provided to all exposed (e.g. psychological first aid); a second level indicated intervention that targets those with low level or emerging mental health problems (e.g. Skills for Psychological Recovery); and a third-level psychological/psychiatric treatment to those who develop mental health disorders. While these approaches all have been developed from the literature, more research is required to ensure that in the years ahead, our psychosocial interventions after natural disaster are evidenced based, not just evidence informed. Future research also needs to address how to best target those who are vulnerable to mental health problems after disaster, with interventions varying in their targeting of specific vulnerabilities. Contributions to the literature such as this one by Parker et al., lead the way in helping us determine a way forward.
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Natural disasters by their very nature occur suddenly and have the potential to cause great harm at an individual, family, community, and societal level. They occur frequently, and with the escalation in extreme events related to climate change, the frequency, and severity of natural disasters will only increase (Intergovernmental Panel on Climate Change (IPCC), Reference Field, Barros, Dokken, Mach, Mastrandrea, Bilir, Chatterjee, Ebi, Estrada, Genova, Girma, Kissel, Levy, MacCracken, Mastrandrea and White2014). Globally, a growing number of people are being exposed to natural disaster; however, the vulnerability to exposure is not equally shared. Those who are socially, physically, economically, culturally, politically, institutionally, or otherwise disadvantaged are especially vulnerable to experiencing natural disaster.
While the immediate health relief response after disaster usually focuses on meeting the physical needs of individuals, there is increasing awareness of the impact of disasters on mental health. People exposed to disasters commonly experience a range of stress-related emotions including disbelief, sadness, anxiety, anger, and grief. Generally these emotions dissipate over time as the process of rebuilding one's life starts to take shape and the survivor harnesses their coping strategies and supports. However, a substantial minority develop a range of mental health conditions. These may include, but not limited to, post-traumatic stress disorder (PTSD), depression, anxiety disorders, and substance use disorders. This mental health burden represents a significant cost to society in addition to the individual, their families, and their social and economic networks. Identifying the factors that contribute to psychological vulnerability is an important component of preparing for and addressing the aftermath of natural disasters.
As such Parker and colleagues’ (Reference Parker2015) examination of the mental health implications of natural disasters for older adults represents a timely contribution to the literature. Using the rigorous methodology of systematic review and random-effects meta-analysis they identified papers that examined the impact of natural disasters on the mental health and psychological distressed experienced by older adults. As part of their inclusion criteria, they required primary outcome measurement of PTSD, depression, anxiety disorders, adjustment disorder, and/or psychological distress, and they used the United Nations definition of older adults, i.e. over 60 years. A total of six papers were identified through this rigorous screening process.
Parker et al. (Reference Parker2015) found that older adults were more likely to experience PTSD symptoms after exposure to natural disasters relative to young adults (OR + 2.11, 95% CI 1.40–3.17). Similarly older adults were more likely to experience adjustment disorder after exposure (OR = 1.73, 95% CI = 1.05, 2.86). Interestingly, the authors did not find an increased risk for depression, anxiety, and psychological distress. These important findings beg the question about what increases older people's risk to poor mental health after natural disaster? It also raises questions about why the vulnerability appears more specific to PTSD compared with depression and anxiety. The authors make the important observation that baseline prevalence of PTSD in non-disaster community samples decreases after age 55 years and thus the higher rate of PTSD found in older adults following natural disaster are probably not due to higher baseline prevalence. Rather, the authors suggest that other risk factors for PTSD may particularly affect older adults. For example, female gender is associated with increased risk to PTSD and given women live longer than men the gender skew might contribute to the findings. Similarly, older persons tend to be over represented in the casualties of sudden onset natural disasters and therefore may have to contend with ongoing stressors such as pain, injury, and bereavement, which in turn contribute to PTSD or adjustment disorder vulnerability. Alternatively, we may also wonder whether greater physical vulnerability that can accompany older age increases the risks for an acute fear response to the threat of disaster, hence increasing the risk of a fear disorder such as PTSD compared with depression.
The study has a number of limitations. As is the case of all systematic reviews/meta-analyses, they are only as good as the studies that meet the inclusion criteria. The authors identified that psychosocial disaster research suffers from poor methodology, a point that was made by Norris (Reference Norris1992) who noted that the quality of the psychosocial disaster research was on the decline particularly in terms of sample size and follow-up periods. Parker and colleagues make the important point that the field requires studies that utilize standardized methodologies so that comparisons can be easily made across studies.
The question this paper leaves us with is what should be done in the aftermath of natural disaster to protect the mental health of individuals, especially those like the elderly, who may have increased vulnerability to poor mental health outcomes. Various international bodies such as the Inter-Agency Standing Committee (IASC) and the NATO Joint Medical Committee have proposed evidenced informed strategic stepped models of care (IASC, 2014; NATO, 2014). Similarly, Forbes et al. (Reference Forbes, Creamer and Wade2012) and their colleagues advocated a stratified approach when they developed and implemented a three-level framework after the 2009 Black Saturday Bushfires in Victoria, Australia. This approach to psychosocial care proposes a universal psychosocial intervention which is provided to all exposed (e.g. psychological first aid); a second level indicated intervention that targets those with low level or emerging mental health problems (e.g. Skills for Psychological Recovery); and a third-level psychological/psychiatric treatment to those who develop mental health disorders. While these approaches all have been developed from the literature, more research is required to ensure that in the years ahead, our psychosocial interventions after natural disaster are evidenced based, not just evidence informed. Future research also needs to address how to best target those who are vulnerable to mental health problems after disaster, with interventions varying in their targeting of specific vulnerabilities. Contributions to the literature such as this one by Parker et al., lead the way in helping us determine a way forward.
Conflict of interest
None.