This article appeared in a journal published by Elsevier. The attached copy is furnished to the author for internal non-commercial research and education use, including for instruction at the authors institution and sharing with colleagues. Other uses, including reproduction and distribution, or selling or licensing copies, or posting to personal, institutional or third party websites are prohibited. In most cases authors are permitted to post their version of the article (e.g. in Word or Tex form) to their personal website or institutional repository. Authors requiring further information regarding Elsevier’s archiving and manuscript policies are encouraged to visit: http://www.elsevier.com/copyright
Author's personal copy
Social Science & Medicine 75 (2012) 1708e1714
Contents lists available at SciVerse ScienceDirect
Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed
Short report
Post-disaster psychosocial services across Europe: The TENTS project Anke B. Witteveen a, *, Jonathan I. Bisson b, Dean Ajdukovic c, Filip K. Arnberg d, Kerstin Bergh Johannesson d, Hendrieke B. Bolding a, Ask Elklit e, Louis Jehel f, Venke A. Johansen g, Maja Lis-Turlejska h, Dag O. Nordanger i, Francisco Orengo-García j, A. Rosaura Polak a, Raija-Leena Punamaki k, Ulrich Schnyder l, Lutz Wittmann l, Miranda Olff a a
Department of Psychiatry e Anxiety Disorders, Academic Medical Center, University of Amsterdam, Meibergdreef 5, 1105 AZ Amsterdam, The Netherlands School of Medicine, Cardiff University, Cardiff, United Kingdom Department of Psychology, Faculty of Humanities and Social Sciences, University of Zagreb, Zagreb, Croatia d National Centre for Disaster Psychiatry, Department of Neuroscience, Uppsala University, Uppsala, Sweden e National Center of Psychotraumatology, Institute of Psychology, University of Southern Denmark, Odense, Denmark f Fort de France University Hospital Center, Antilles-Guyane University, Fort de France, Martinique g Resource Center on Violence, Traumatic Stress and Suicide Prevention, Western Norway (RVTS West), Haukeland University Hospital, Norway h Warsaw School of Social Sciences and Humanities, Warsaw, Poland i Centre for Child and Adolescent Mental Health, Bergen, Norway j Sociedad Española de Psicotraumatología y Estrés Traumatico (SEPET), Madrid, Spain k School of Social Sciences and Humanities/Psychology, University of Tampere, Finland l Department of Psychiatry, University Hospital Zurich, Switzerland b c
a r t i c l e i n f o
a b s t r a c t
Article history: Available online 14 July 2012
At present post-disaster activities and plans seem to vary widely. An adequate estimation of the availability of post-disaster psychosocial services across Europe is needed in order to compare them with recently developed evidence-informed psychosocial care guidelines. Here we report on the results of a cross-sectional web-based survey completed in 2008 by two hundred and eighty-six representatives of organizations involved in psychosocial responses to trauma and disaster from thirty-three different countries across Europe. The survey addressed planning and delivery of psychosocial care after disaster, methods of screening and diagnosis, types of interventions used, and other aspects of psychosocial care after trauma. The findings showed that planning and delivery of psychosocial care was inconsistent across Europe. Countries in East Europe seemed to have less central coordination of the post-disaster psychosocial response and fewer post-disaster guidelines that were integrated into specific disaster or contingency plans. Several forms of psychological debriefing, for which there is no evidence of efficacy to date, were still used in several areas particularly in North Europe. East European countries delivered evidence-based interventions for PTSD less frequently, whilst in South- and South-Eastern European countries anxiety suppressing medication such as benzodiazepines were prescribed more frequently to disaster victims than in other areas. Countries across Europe are currently providing sub-optimal psychosocial care for disaster victims. This short report shows that there is an urgent need for some countries to abandon non-effective interventions and others to develop more evidence based and effective services to facilitate the care of those involved in future disasters. Ó 2012 Elsevier Ltd. All rights reserved.
Keywords: Europe Disaster Trauma Mapping Psychosocial response Post traumatic stress disorder Survey
Introduction Over recent decades the knowledge base on psychosocial responses after trauma has increased greatly. For example, several evidence-based guidelines for post traumatic stress disorder (PTSD) * Corresponding author. Tel.: þ31 (0)208913661. E-mail addresses:
[email protected], (A.B. Witteveen).
[email protected]
0277-9536/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.socscimed.2012.06.017
have been developed (Foa, Keane, Friedman, & Cohen, 2009; NICE, 2005) and recommend first-line treatments with a considerable evidence base such as trauma-focused cognitive behavioural therapy (CBT), Eye Movement Desensitization and Reprocessing (EMDR) (Bisson & Andrew, 2007) or selective serotonin reuptake inhibitors (SSRIs) (Stein, Ipser, & Seedat, 2006). Recently, guidelines were developed for post-disaster psychosocial care based on the current research evidence and expert consensus (Bisson et al., 2010). These guidelines primarily recommended that every area
Author's personal copy
A.B. Witteveen et al. / Social Science & Medicine 75 (2012) 1708e1714
should have a multi-agency psychosocial care planning group, that early application of formal interventions for all should not occur, that trauma-focused CBT should be used as the first-line intervention for acute stress disorder and acute PTSD, and traumafocused CBT or EMDR for chronic PTSD. In order to accurately disseminate and implement evidenceinformed post-disaster guidelines such as those formulated by (Bisson et al., 2010), knowledge of existing service provision is essential. It has not been clear to what extent evidence based, or at least evidence informed, practices are currently available or implemented in post-disaster psychosocial management throughout Europe. Post-disaster psychosocial activities and plans (if present) seem to vary widely across nations. Evidence-based interventions may not be available and non evidence-based interventions may still be used. To address these issues, The European Network for Traumatic Stress (TENTS) was launched in May 2007. One of the aims of TENTS was to compare its evidence-informed guidelines with existing planning and provision of psychosocial services to disaster victims across Europe in order to appropriately plan dissemination and ultimately implementation of them. This paper reports the mapping of the existing planning and provision of psychosocial services.
Table 1 Numbers of participants per country per area. Area
Country
N
West (23%; n ¼ 64)
Belgium The Netherlands Northern-Ireland United Kingdom
5 35 1 23
North (15%; n ¼ 43)
Denmark Finland Norway Sweden
2 13 17 11
Central (25%; n ¼ 72)
Austria Germany Switzerland
2 51 19
South (7%; n ¼ 19)
France Italy Malta Portugal Spain
East (10%; n ¼ 30)
Czech Republic Latvia Lithuania Poland Slovakia
7 3 3 16 1
South-East (20%; n ¼ 58)
Bulgaria Bosnia-Herzegovina Croatia Cyprus FYROM Georgia Greece Romania Serbia Slovenia Turkey
1 4 6 2 2 3 2 5 6 1 26
Method Mapping procedure The international, multi-agency group of TENTS main partners (from fifteen countries and all with expertise in the trauma field) designed the mapping procedure which had three main aims: 1) to build a network of trauma experts across Europe in order to have access to the necessary information, 2) to develop and administer a web-based survey to assess currently available services for the psychosocial care and management for victims of natural and other disasters, and 3) to collect qualitative data through local visits to EU (candidate) member states. Qualitative and quantitative data was to be collected in a standardized and structured manner covering the following areas: planning and delivery systems (e.g. guidelines for psychosocial response following trauma/disasters, contingency plans); methods of screening for trauma/disaster related disorders; treatments for post traumatic disorders, and training and supervision of care providers. Network building The project’s main partners were allocated different areas of the European region and liaised with local organizations in these countries to map current service provision (Table 1). At the same time, other collaborating partners provided information and contacts mainly from their own countries. These included clinicians and emergency planners who represented services and organizations in the field of psychosocial care and post traumatic stress management for victims of psychological trauma and of natural and other disasters, e.g. hospitals and clinics, governmental and nongovernmental organizations, profit and non-profit organizations. Mapping tool A web-based survey, the Disaster Care Mapping Questionnaire (DCMQ), comprising 28 main questions was developed and piloted at the Academic Medical Centre in Amsterdam. Drafts of the survey were circulated to the project partners for consultation to achieve optimal face and content validity. It was subsequently piloted within the consortium of partners, adjusted and re-tested before being integrated in the website. The DCMQ included dichotomous, multiple choice and open-ended questions which were divided into 6 sections:
1709
4 4 1 5 5
FYROM ¼ Former Yugoslavian Republic of Macedonia.
1) demographics of participant and organization (e.g., types of psychosocial care delivered) 2) planning and delivery systems (e.g., participation in multiagency coordination of disaster response or use of specific post-disaster guidelines and contingency plans) 3) target populations of service provision (e.g., children or victims of war) 4) screening and diagnostic instruments in use (e.g., structured diagnostic interviews or questionnaires) 5) interventions (e.g., immediate interventions, psychological, pharmacological and community based interventions including subtypes of each) 6) education, training, supervision and needs of service providers The survey was translated (and back translated) into six local languages (i.e., Turkish, Finnish, Hungarian, Polish, Spanish, Swedish and French) and administered between May and December 2008. Interviews The TENTS main partners visited key contacts in the countries they liaised with during the mapping process. The visiting partners organized an interview with the key local contact(s) or set up a focus group to meet with several key local contacts. The partner interviewed the contacts about local planning and delivery systems (e.g., coordination of care), methods of screening, assessment and interventions for trauma-related
Author's personal copy
1710
A.B. Witteveen et al. / Social Science & Medicine 75 (2012) 1708e1714
disorders, and training and supervision of care providers. The interview was semi-structured and used open-ended questions to allow the contacts to respond as they saw fit. The visiting partner took notes of the interview, transcribed it into a qualitative report and filled out a needs assessments form of local provision of psychosocial care using the TENTS guidelines as a gold standard. These qualitative needs analyses per country have been used to further support and explain the quantitative data gathered and reported in this paper. Participants An invitation e-mail was sent to the 652 individuals who were identified as a source of information within a particular country. They were invited to complete the DCMQ for their affiliated organization. Nearly half of them (n ¼ 286; 44%) completed the questionnaire (see Fig. 1). Most participants were providers of psychosocial care (50.3%) and/or (mental health care) managers (30.1%). The rest were researchers (18.5%), educators (15.7%), policy makers (8%) or a combination of those. Around half of all participants reported that their affiliated organization had one main function, for example being a hospital or clinic. 82.2% of all participants indicated that their organization was involved in some kind of psychosocial support or care, 55.2% in both psychosocial care delivery and its planning and coordination, while 10.8% reported that their affiliated organization was only involved in planning and coordinating the post-disaster psychosocial response. Another 10% indicated that they were involved in something else unrelated to psychosocial care or planning and coordination of the disaster response, such as trauma research. Analysis Outcomes of the survey were coded into binary variables (‘Yes’ into 1; ‘No’, ‘Don’t know’, and ‘Not applicable’ into 0). Cross tabs with Pearson chi-square tests were performed in SPSS version 18 for Windows to determine the proportions for each area and to test whether the six areas differed significantly. The chi-square approximation is, however, inadequate when sample sizes are small, or the data are very unequally distributed among the cells of the table. When the expected values in any of the cells of a contingency table were below 5, the Fisher exact test was used.
Results Demographics and organizational background Areas differed significantly regarding the proportion of organizations which responded with the following main functions: hospitals (df ¼ 5, c2 ¼ 14.7, p < .05), NGOs (df ¼ 5, c2 ¼ 14.7, p < .05), governmental emergency services (df ¼ 5, c2 ¼ 13.7, p < .05), and social services (df ¼ 5, c2 ¼ 15.8, p < .01). More specifically, in West Europe relatively few participants had a hospital or clinic as their main affiliated organization (13%) compared to participants from North and Central Europe (42% and 33%, respectively). More than a third (38%) of participants from South-East Europe worked in NGOs, while in North Europe this proportion was only 7%. Governmental emergency services were the most common affiliation of participants from South Europe (38%) and least common in Central and South-East Europe (around 5% each). More than 20% of participating organizations from West Europe were social services compared to only 2% in North Europe. Planning and delivery systems In general, areas differed significantly regarding the proportion of participants with affiliated organizations involved in planning and coordination of the delivery of psychosocial support/care for victims of disasters (df ¼ 5, c2 ¼ 17.5, p < .01). In particular, in North Europe a relatively high proportion of organizations were involved in planning and coordination of the post-disaster psychosocial response compared to, for example, East Europe (see Fig. 1 for exact numbers and percentages by area). Within the specific domains, Fig. 1 shows that the six areas differed significantly regarding the proportions of organizations involved in the central coordination of the delivery of psychosocial services (df ¼ 5, c2 ¼ 19.7, p ¼ .001) and the proportions of organizations per area that follow specific postdisaster guidelines (df ¼ 5, F ¼ 14.5, p < .05). More specifically, only 31% of organizations from East Europe were involved in central coordination as opposed to 70e80% of organizations from other areas. Regarding following post-disaster guidelines, the lowest proportions were found for East and South-East Europe. Of the organizations following specific disaster guidelines, areas differed significantly in the proportion that had integrated the guidelines into a specific disaster or contingency plan (df ¼ 5, c2 ¼ 11.4, p < .05). Generally, East and South-East European areas had integrated guidelines into a specific disaster plan less frequently than other European areas (60 and 50% versus 76e90%).
Fig. 1. Planning and coordination.
Author's personal copy
A.B. Witteveen et al. / Social Science & Medicine 75 (2012) 1708e1714
Target groups for psychosocial care or support Fig. 2 shows that areas were different regarding the delivery of psychosocial care/support to various types of trauma victims (df ¼ 5, c2 ¼ 16.2, p < .01), to victims of war (p < .05, Fishers Exact Test) and victims of motor vehicle accidents (MVA) (df ¼ 5, c2 ¼ 16.1, p < .01). More specifically, the proportion of organizations in East Europe that targeted psychosocial care to various types of trauma victim instead of certain specific groups, was particularly low (26%) compared to other areas (53e72%) and the proportions of organizations in SouthEast Europe that targeted psychosocial care specifically to victims of war was relatively high (i.e. 38%) compared to other areas such as South and Central Europe (around 12%). On the contrary, a relatively high proportion (i.e. 50%) of organizations from Central Europe (and to a certain extent also in North, East and South Europe) targeted their psychosocial care to victims of MVA compared to South-East and West Europe (18 and 22%, respectively). Screening and diagnosing In general, areas were not different regarding the proportion of organizations that performed screening of adults at risk for developing trauma-related disorders (47e62%) or diagnosing traumarelated disorders such as PTSD or ASD (50e65%). The same applied to screening and diagnosing children at risk for developing trauma-related disorders (9e31% for screening and 13e21% for diagnosing). Interventions Immediate interventions As shown in Table 2, a significant difference was found regarding the proportion of organizations per area delivering psychological debriefing in the immediate aftermath of disaster (df ¼ 5, c2 ¼ 12.3, p ¼ .03). More specifically, the data shows that more than half of the organizations in North Europe delivered psychological debriefing
1711
to disaster victims compared to lower rates in West, East and South-East Europe (around 25%). A closer look at the data, through free text data and the qualitative information from the local visits, explained that psychological debriefing in North Europe comprised several forms; 35% group debriefing, 22% Critical Incident Stress Debriefing (CISD; a multi component group (or sometimes individual) crisis intervention), 21% individual psychological debriefing and 22% were undefined. There were no significant differences between areas for community based interventions and subtypes of these interventions (e.g., housing, information or advocacy and legal support). Psychological interventions A significant difference was found regarding the proportion of organizations per area (df ¼ 5, c2 ¼ 14.6, p ¼ .01) delivering psychological interventions to disaster victims, for example a relatively low proportion of organizations in South Europe (see Table 2). Areas differed significantly regarding the delivery of EMDR (i.e., p < .001; Fishers Exact Test); none of the organizations from East Europe indicated they delivered EMDR as opposed to 60% and 70% of organizations from West and North Europe. Organizations from East Europe more frequently delivered psychodynamic therapy to victims of disaster (p < .01; Fishers Exact Test); 80% of organizations from East Europe reported doing so. Participants were asked regarding the use of several cognitive or behavioural techniques in the delivery of psychological interventions, i.e. exposure, cognitive restructuring, stress inoculation training, and psychoeducation. No significant differences between areas were found when comparing the proportions by area for all four approaches separately. However, a trend was clearly noticeable indicating that, besides psychoeducation, the cognitive and behavioural techniques were the least often utilized psychological interventions by organizations from East Europe (ranging from 35 to 50%). Most participants from West Europe indicated that their organization used a form of exposure (75%) compared to proportions of around 50% in other areas.
Fig. 2. Target groups of care.
Author's personal copy
1712
A.B. Witteveen et al. / Social Science & Medicine 75 (2012) 1708e1714
Table 2 Proportions of organizations per area delivering interventions for victims of disaster. Interventions for victims of disaster
West (%)
North (%)
East (%)
South (%)
East (%)
South-East (%)
N delivering psychosocial care Psychological debriefing* Critical incident stress management Community based interventions Psychological interventions* Pharmacological interventions
53 26.4 11.3 20.8 54.7 23.5
35 54.3 17.1 34.3 71.4 26.5
61 39.3 26.2 21.3 77 34.5
14 42.9 21.4 28.6 35.7 45.5
23 26.1 17.4 26.1 60.9 20.8
48 22.5 8.3 45.8 75 44.7
N delivering psychological interventions TF-CBT EMDR*** BEP Psychodynamic** Exposure Cognitive restructuring Stress inoculation training Psychoeducation
29
25
47
5
14
36
62.1 72.4 37.9 13.8 75.9 82.8 55.2 62.1
40 60 40 56 56 76 60 40
44.7 29.8 29.8 34 61.7 70 63.8 55.3
40 40 60 80 60 60 60 40
21.4 0 14.3 14.3 35.7 50 42.9 50
50 30.6 50 25 55.6 69.4 58.3 58.3
12
9
20
5
5
21
58.3 16.7 25 33.3 16.7
66.7 22.2 22.2 44.4 22.2
95 35 5 55 25
80 60 80 40 40
40 40 20 40 40
81 66.7 38.1 52.4 61.9
N delivering pharmacological interventions Antidepressants* Anxiolytics* Sympathicolytics* Antipsychotics Mood stabilizers
*p < .05, **p < .01, ***p < .001. TF-CBT (trauma-focused cognitive behavioural therapy), EMDR (Eye Movement Desensitization Reprocessing), BEP (Brief Eclectic Psychotherapy); antidepressants (i.e., selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, tricyclic antidepressants, novel antidepressants), anxiolytics (i.e., benzodiazepines and non-benzodiazepines), symphaticolytics (i.e., propranolol, prazosin), antipsychotics (i.e., typical and atypical antipsychotics), and mood stabilizers (i.e., lamotrigine, carbamazepine, topiramate, lithium carbonate, valproate).
Pharmacological interventions Areas did not differ significantly regarding the proportion of organizations delivering pharmacological interventions in general, however, areas differed per subclass of psychoactive medication (Table 2) The areas significantly differed in the prescription of antidepressants, anxiolytics/sleep medication and sympatholytics to victims of disaster (for all p < .05, Fishers Exact Tests). Looking into more detail, these differences seem to be determined by the relatively high prescription rates of anxiolytics like benzodiazepines to disaster victims within organizations from the South and South-East European areas compared to other areas. Regarding antidepressants, relatively high proportions (81e95%) of organizations from Central, South and South-East Europe prescribed antidepressants to disaster victims compared to other areas. Four out of five organizations (80%) from South European countries used sympatholytics (e.g., propranolol or prazosin) to disaster victims, which was high compared to other areas (5e38%). Supervision and training In all areas, 41.7e60.7% of organizations provided some form of training either to professionals or volunteers involved in the delivery of psychosocial care or support. 58.5e70.5% of participants from all areas except South Europe (28.7%) reported that their organization had supervision available for their professionals or volunteers involved in the delivery of psychosocial support or care to disaster victims. Areas were, however, not significantly different in terms of providing training and supervision. Discussion and conclusions Psychosocial support has, since the mid 1990s, become an increasingly important component of disaster preparation and response (e.g. Galea et al., 2002; Norris et al., 2002; Weaver, 1995).
In Europe, policy- and decision-makers, health-professionals, researchers and other experts have become increasingly aware of the nature and extent of psychosocial needs after mass emergencies and disasters; this is reflected in several papers and local initiatives (e.g., De Roos et al., 2011; Purtscher, 2005; Seynaeve, 2001; Zaetta, Santonastaso, & Favaro, 2011). International European bodies, such as WHO-Europe and the European Union, have, over the past decade, addressed risk and disaster prevention by encouraging and recommending the application of measures to develop personal and social resilience in the face of threats and disasters (Council of Europe, 2010). Furthermore, the impression of a striking variety in activities, methods and approaches to the provision of psychosocial support, depending upon prevailing theories, economic resources, culture and local situations, has resulted in several projects. These projects are mostly co-funded by the EU or WHO-Europe, and have a special emphasis on improving the provision of psychosocial support in certain areas and countries of Europe, e.g. East- and Southern Europe, and for certain vulnerable groups in the aftermath of mass emergency situations, e.g. children and elderly. These projects should, ideally through networks of local experts, disseminate and implement evidenceinformed guidelines for post-disaster psychosocial care into routine practice in settings across a large geographical area. Before conducting the current project, it was, therefore, essential to obtain accurate knowledge regarding the existing situation. The mapping survey on psychosocial care after disasters has allowed relevant data from a large geographical area to be gathered. The findings of the survey support the impression of a variety of activities, methods and approaches to the provision of psychosocial support and reveal inconsistencies across Europe in planning, coordination and psychosocial care delivery for disaster victims. In particular, in East Europe there seemed to be a lack of central coordination of the post-disaster psychosocial response and a lack of integration of post-disaster guidelines into specific disaster or
Author's personal copy
A.B. Witteveen et al. / Social Science & Medicine 75 (2012) 1708e1714
contingency plans. While there have been initiatives in central coordination of psychosocial post-disaster responses in East Europe (Vymetal, 2006), this area needs more central coordination of the response and a larger degree of implementation of post-disaster guidelines. Well coordinated planning and cooperation with local authorities and services are recommended in the guidelines of TENTS (Bisson et al., 2010) and previous reports have also shown the importance of successful participation in pre-disaster, consensus-building disaster planning processes to improve the effectiveness of response operations and community coordination (Kapucu, 2008). In general, the rate of involvement in formal assessment (i.e., screening and diagnosing) of disaster victims at risk for traumarelated disorders appeared relatively low. Whilst not formally screening everyone following a traumatic event is consistent with the TENTS guidelines, the data suggest a need for the whole European region to increase formal assessment, in particular of the groups most vulnerable to suffer from psychological morbidity in response to disaster (Somasundaram & van de Put, 2006). The TENTS guidelines recommend the follow up of those individuals at highest risk and the provision of evidence-based treatment for those having significant difficulties after formal assessment (Bisson et al., 2010). Regarding delivery of psychosocial care or support to victims of trauma and disaster, areas differed in the extent to which they delivered this care to groups with different trauma backgrounds. This may well reflect the recent histories of these areas, e.g., with the Balkan Peninsula having been greatly affected by wars in the 1990s and Spain and the United Kingdom by large-scale terrorist attacks in 2004 and 2005, respectively. Our results also suggest that East European and to a certain extent South- and South-East European countries deliver less evidence-based psychological interventions for PTSD such as trauma-focused CBT and EMDR and relatively more anxiety suppressing medications such as benzodiazepines. A rather contradictory finding was the high proportion of organizations in North Europe delivering evidence-based psychological interventions or techniques for victims of disaster but also psychological debriefing for which there is no clear evidence base. The extent of deployment of psychological debriefing in North Europe suggests a general need for critical evaluation of its use and content particularly when it concerns a single session individual debriefing for direct trauma victims as this has been found harmful for example in MVA-victims (Mayou, Ehlers, & Hobbs, 2000; Rose, Bisson, Churchill, & Wessely, 2002). Also, more research into the efficacy of other forms of debriefing in specific populations is necessary. Concerning other immediate interventions, it is noteworthy that community based interventions such as providing material resources seem well embedded in the psychosocial response, particularly in South-East Europe, which is reassuring as this may prevent psychological distress (Galea et al., 2002; Hobfoll et al., 2007). Although one out of two organizations per area (except East Europe) delivered guideline-supported trauma-focused CBT for individuals with ASD or (acute) PTSD (Bisson et al., 2010; Foa et al., 2009; NICE, 2005), further dissemination and implementation may be warranted, for example to inexpert trauma therapists who can be trained in short time spans in a post-disaster situation (Hamblen, Norris, Gibson, & Lee, 2010). EMDR, which has a growing evidence base for (chronic) PTSD (Bisson & Andrew, 2007) and should be available for disaster victims with acute PTSD if TF-CBT is not tolerated or absent (Bisson et al., 2010), seems reasonably available in West and North Europe while it is less (or not) available in other areas (i.e., South-East and Central and -East Europe). Previous trauma response programs show that the established psychological treatments of TF-CBT and EMDR can be effective in substantially reducing PTSD rates in the first year after disaster
1713
(Brewin et al., 2010). Although psychodynamic therapy may address clinical features of PTSD that are not targeted by current empirically supported treatments of (complex) PTSD (Schottenbauer, Glass, Arnkoff, & Gray, 2008), its relatively frequent use in some European areas should not be encouraged since there is no convincing evidence that it reduces the core PTSD symptoms as significantly as TF-CBT, EMDR or stress management (Bisson & Andrew, 2007). Taking into account the high prescription rates of medication for PTSD in clinical practice (Mellman, Clark, & Peacock, 2003), it is quite striking that the results of this survey show a relatively low delivery rate of pharmacotherapy to victims of disaster throughout Europe. The fact that no consensus for the provision of access to pharmacological assessment and management in the aftermath of disaster was reached during the development of the TENTS guidelines (Bisson et al., 2010) indeed points to a certain hesitation for providing medication in the treatment of trauma-related disorders to victims of disaster. The data, however, show that some areas (i.e. South and South-East Europe) seem to deliver second-line psychotropic medications for PTSD, in particular, anxiety suppressing medications like benzodiazepines, to symptomatic disaster victims significantly more often than others. Although short-term benzodiazepine use may reduce anxiety and improve sleep, adverse consequences of benzodiazepine treatment among patients with PTSD have been reported (Brown & Freeman, 2009) and their use for treatment of PTSD or ASD is not recommended (Davidson, 2006; Foa et al., 2009). Limitations and strengths This study does have some limitations. Firstly, with a nonresponse of over 50% on the survey the data may not truly reflect the existing psychosocial services for disaster victims across Europe. Secondly, the structured survey mapped only the availability of certain psychosocial services and not the extent or frequency of delivery of these psychosocial services to disaster victims. Thirdly, differences between areas in function or types of organization represented may have obscured the mapping results. An important strength of this study should also be noted. Although there have been some studies on mental health service utilization after specific disasters (Rodriguez & Kohn, 2008), this is the first study that has examined the availability and delivery or provision of post-disaster psychosocial services reported by a broad range of organizations from several areas that have different histories in trauma and disaster work and who have different historic and cultural backgrounds. Implications The mapping data collected provides rich information on the existing situation with regard to the planning and delivery of postdisaster psychosocial care in Europe and reflects the key needs of different areas within Europe. It provides a basis for the development of tailored training modules, which allow implementation of the recommendations of the TENTS guidelines. The range of needs for the planning and delivery of post-disaster psychosocial care in Europe may challenge organizations to critically evaluate their own post-disaster response and may lead to abolishment of noneffective interventions and implementation of evidence based and effective services in the response to future disasters. Acknowledgements We wish to express thanks to all participants of the mapping survey. This study was (co-)funded by a grant from the European Union (Executive Agency of Health and Consumers). The study
Author's personal copy
1714
A.B. Witteveen et al. / Social Science & Medicine 75 (2012) 1708e1714
sponsor played no role in study design and the collection, analysis, and interpretation of data and the writing of the article and the decision to submit it for publication. ABW was responsible for the design, logistic support, data collection, analysis of the data, and writing of the manuscript. MO and JIB were responsible for conception and design. JIB, DA, KBJ, FA, LJ, AE, DON, MLT, VAJ, FOG, RLP, US and LW and MO were responsible for design and data collection. MO had a supervisory role over data collection, data analysis and writing of the manuscript. HBB and ARP were responsible for data collection and logistic support. All authors critically revised the manuscript and approved the final version and had access to all data. The current paper comprises original material which has not been published elsewhere. References Bisson, J., & Andrew, M. (2007). Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database Systematic Reviews, 18, CD003388. Bisson, J. I., Tavakoly, B., Witteveen, A. B., Ajdukovic, D., Jehel, L., Johansen, V. J., et al. (2010). TENTS guidelines: development of post-disaster psychosocial care guidelines through a Delphi process. British Journal of Psychiatry, 2010(196), 69e74. Brewin, C. R., Fuchkan, N., Huntley, Z., Robertson, M., Thompson, M., Scragg, P., et al. (2010). Outreach and screening following the 2005 London bombings: usage and outcomes. Psychological Medicine, 40, 2049e2057. Brown, M., & Freeman, S. (2009). Clonazepam withdrawal-induced catatonia. Psychosomatics, 50, 289e292. Council of Europe. (2010). Council conclusions on psychosocial support in the event of emergencies and disasters. Public register of council documents, Brussels, Belgium. Davidson, J. R. (2006). Pharmacologic treatment of acute and chronic stress following trauma. Journal of Clinical Psychiatry, 67, 34e39. De Roos, C., Greenwald, R., Hollander-Gijsman, M., Noorthoorn, E., Buuren, S., & de Jongh, A. (2011). A randomised comparison of cognitive behavioural therapy (CBT) and eye movement desensitisation and reprocessing (EMDR) in disaster exposed children. European Journal of Psychotraumatology, 2. http://dx.doi.org/ 10.3402/ejpt.v2i0.5694. Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A. (Eds.), (2009). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (2nd ed.). New York: Guilford Publications. Galea, S., Ahern, J., Resnick, H., Kilpatrick, D., Bucuvalas, M., Gold, J., et al. (2002). Psychological sequelae of the September 11 terrorist attacks in New York City. New England Journal of Medicine, 346, 982e987.
Hamblen, J. L., Norris, F. H., Gibson, L., & Lee, L. (2010). Training community therapists to deliver cognitive behavioral therapy in the aftermath of disaster. International Journal of Emergency Mental Health, 2010(12), 33e40. Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., et al. (2007). Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence. Psychiatry, 70, 283e315. Kapucu, N. (2008). Collaborative emergency management: better community organising, better public preparedness and response. Disasters, 32, 239e262. Mayou, R. A., Ehlers, A., & Hobbs, M. (2000). Psychological debriefing for road traffic accident victims. Three-year follow-up of a randomised controlled trial. British Journal of Psychiatry, 176, 589e593. Mellman, T. A., Clark, R. E., & Peacock, W. J. (2003). Prescribing patterns for patients with posttraumatic stress disorder. Psychiatric Services, 54, 1618e1621. National Institute for Health and Clinical Excellence. (2005). Post-traumatic stress disorder (PTSD): The management of PTSD in adults and children in primary and secondary careIn Clinical guideline, Vol. 26. London: National Institute for Health and Clinical Excellence, CG26. Norris, F. H., Friedman, M. J., Watson, P. J., Byrne, C. M., Diaz, E., & Kaniasty, K. (2002). 60,000 Disaster victims speak: part I. An empirical review of the empirical literature, 1981e2001. Psychiatry, 65, 207e239. Purtscher, K. (2005). Preparing and responding to major accidents and disasters. International Journal of Injury Control and Safety Promotion, 12(2), 119e121. Rodriguez, J. J., & Kohn, R. (2008). Use of mental health services among disaster survivors. Current Opinion in Psychiatry, 21, 370e378. Rose, S. C., Bisson, J., Churchill, R., & Wessely, S. (2002). Psychological debriefing for preventing posttraumatic stress disorder (PTSD). Cochrane Database Systematic Reviews, 2, CD000560. Schottenbauer, M. A., Glass, C. R., Arnkoff, D. B., & Gray, S. H. (2008). Contributions of psychodynamic approaches to treatment of PTSD and trauma: a review of the empirical treatment and psychopathology literature. Psychiatry, 71, 13e34. Seynaeve, G. J. R. (Ed.), (2001). Psycho-social support in situations of mass emergency. A European policy paper concerning different aspects of psychological support and social accompaniment for people involved in major accidents and disasters. Brussels, Belgium: Ministry of Public Health. Somasundaram, D. J., & van de Put, W. A. (2006). Management of trauma in special populations after a disaster. Journal of Clinical Psychiatry, 67(2), 64e73. Stein, D. J., Ipser, J. C., & Seedat, S. (2006). Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database Systematic Reviews, 25, CD002795. Vymetal, S. (2006). Central system of psychosocial support to the Czech victims affected by the tsunami in Southeast Asia. Prehospital Disaster Medicine, 21, 27e31. Weaver, J. D. (1995). Disasters: Mental health interventionsIn Crisis management series, Sarasota, FL, US: Professional Resource Press/Professional Resource Exchange. Zaetta, C., Santonastaso, P., & Favaro, A. (2011). Long-term physical and psychological effects of the Vajont disaster. European Journal of Psychotraumatology, 2. http://dx.doi.org/10.3402/ejpt.v2i0.8454.
