In disasters and other mass casualty incidents, otherwise known as MCIs, medical first responders such as paramedics and emergency room physicians and nurses are often called upon to respond, both within the emergency department (ED) and in the field. The roles of emergency medical ser-vices (EMS) and the ED in disasters and other mass public health emergencies have become increasingly evident in recent years (1,2). Hospitals, government agencies, and public health services have expended much effort to train, educate, and equip medical personnel. With varying success, medical personnel have also participated in disaster exercises testing disaster response plans (3,4).

However, an area of disaster planning that needs greater focus and attention is the role of emergency mental health professionals and, where one exists, an organized psychiatric emergency service (PES). (The term PES staff is used in this chapter to refer to any emergency mental health professional.) Many individuals who experience psychiatric distress from disasters will seek care through the ED. One study found a 10% temporal increase in the rate of ED behavioral and mental health diagnoses among Medicaid enrollees within a 3-mile radius of the World Trade Center site in New York City after the September 11th terrorist attack (5). Besides the direct psychiatric stresses on individuals, which are discussed later in this chapter, distress caused by disasters can also adversely influence how individuals and communities seek and access postdisaster medical care and social services.

Disaster mental health services must be actively integrated into emergency medicine at every stage and in each component of disaster response, and PESs are vital to the overall EMS response. PES staff are accustomed to working in crises and in multidisciplinary team formats; they interface regularly with ED staff and other professionals in providing clinical care and often work with first responders such as EMS and police. Such preexisting relationships are helpful in developing trust and as foundations for further collaboration and cooperation in disaster planning. Additionally, the PES is a natural leader of a community’s collaborative mental health response to disasters because EMS and medical emergency services will undoubtedly be at the forefront of any public health response to disasters and public health emergencies. Likewise, PES is the crisis intervention arm of psychiatry.

The PES faces a variety of challenges to disaster planning. Like general medical EDs, PESs are often underresourced and overcrowded (6). Additionally, EDs and PESs are rarely integrated, and communication and collaboration between the two services are insufficient. The PES and the ED often operate as separate, distinct services. Even when integrated, the two services have distinct cultures and structures that are often not fully understood by the other. There may be stigma toward both psychiatric clinicians and patients with mental illness or psychological issues, who are viewed as troublesome or demanding to a system that is already stretched. Psychological issues have not traditionally been viewed as a priority for both clinical care and staff wellness. Administrators may also view the needs of the PES as secondary (7).

A disaster is an event that overwhelms the preexisting coping capabilities of a community. Disasters can be massive events affecting a large number of
people or a large area, or they can be localized. However, disasters affect communities as a whole. In addition to the primary disaster victims and their immediate families, the effects of disaster can extend to other family members, friends, coworkers, and caregivers, including medical professionals, through secondary traumatization. In any plan for disaster preparation, response, and recovery, it is important for PESs to look beyond serving the needs of the affected individuals to consider planning and interventions with a greater public health perspective.

Not all disasters are the same. Disasters have characteristics that can mitigate or exacerbate psychiatric distresses. Natural disasters may bring up issues that are different from those of human-made disasters, including terrorism (8). The amount of death, injuries, and property destruction resulting, as well as the size of the affected geographic area and the duration of the event, can influence how at risk individuals and communities will be. Some disasters may necessitate a more immediate and robust response from mental health services, including PESs, with a lesser demand for mental health services beyond, whereas others may require more sustained efforts and commitment by mental health services over a longer period of time.

Other factors that may influence the psychiatric burden of disasters include the natures of the community and the individuals who are affected. The level of social support and an individual’s preexisting medical or psychiatric comorbidities, age, and gender have also been demonstrated to be factors in risks of psychiatric disorders after trauma (9).

PESs must appreciate the disaster response structure that is in place. This understanding ensures the clinical assessment of needs and the efficient delivery of mental health services and empowers PESs to become involved and integrated into the structure so that they can become part of the overall disaster planning process (10, 11, 12).

Command and control issues are an important component of any disaster response (13). PESs need to recognize two main disaster response hierarchies: an external hierarchy and an internal hierarchy. The external hierarchy refers to the community at large. Depending on the type and severity of disaster, various state and federal agencies, including the Federal Emergency Management Agency (FEMA), and nongovernmental agencies, such as the American Red Cross (ARC), may be involved. It is important to understand the roles and functions of these agencies, which may provide mass care and shelter, medical services, or financial benefits. A familiarity with these agencies ensures that PESs appropriately consider needs assessment, interventions, and, most important, collaboration.

Most response agencies’ responsibilities in di-sasters are defined by roles using a model called the incident command structure (ICS) or incident management system (IMS). IMS establishes overall command function, including logistics, planning, operations, finance/administration, safety, and public information (14,15). The National Incident Management System (NIMS) is the national IMS that defines the responsibilities of the various agencies that may respond in a national emergency. NIMS helps ensure a greater degree of management and coordination of resources (16).

Internal structure refers to the institution or hospital system of which the PES may be a part. Every hospital should have a disaster response plan that specifies each department’s responsibilities. Many hospitals use the Hospital Emergency Incident Command System (HEICS), which is similar to NIMS, with the same principles of identifying clear roles and functions for all responsible departments in a disaster and ensuring coordination of those departments (17,18). Although HEICS is designed for a hospital response, such a system should still be implemented if the response occurs off-site (e.g., at a Family Assistance Center), so as to help coordinate resources and responsibilities (19). PESs should plan how they will work with the hospital’s HEICS as well as having their own response plan to continue functioning in a disaster. Table 39.1 describes the roles of each IMS function.

The psychological consequences of disasters have become increasingly clear in recent years. These include posttraumatic stress disorder (PTSD),
major depression, anxiety disorders, and substance abuse disorders (9,20,21). Disaster can also evoke a wide spectrum of stress reactions (22). These stress reactions and behavioral changes may be induced by the disaster itself or by the chaotic environment typical of disaster responses (23). Although many of these reactions are common or expected in the aftermath of a disaster, it is important for clinicians to identify any associated functional impairment in determining when and where interventions are needed. Additionally, these reactions and changes often influence how individuals interpret and respond to disasters, such as how individuals seek postdisaster medical care and social services. Disaster stress reactions tend to fall into several categories: physical, emotional, cognitive, behavioral, and spiritual. Table 39.2 lists specific examples of each category.

From a response perspective, disaster-induced stress reactions can influence the management of such events (24,25). Surge capacity, the sudden increased demand for medical services in disaster, is a likely postdisaster concern that may be influenced by distress behavior (26,27). It is anticipated that hospitals will experience a surge capacity equal to 27% of licensed beds (28

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