You are on page 1of 20


The establishment of a standard

operation procedure for psychiatric
service after an earthquake
Chao-yueh Su, Frank Huang-Chih Chou, Kuan-Yi Tsai and Wen-Kuo Lin1

This study presents information on the design and creation of a standard operation procedure
(SOP) for psychiatric service after an earthquake. The strategies employed focused on the
detection of survivors who developed persistent psychiatric illness, particularly post-traumatic stress
and major depressive disorders. In addition, the study attempted to detect the risk factors for
psychiatric illness. A Disaster-Related Psychological Screening Test (DRPST) was designed
by five psychiatrists and two public health professionals for rapidly and simply interviewing
4,223 respondents within six months of the September 1999 Chi-Chi earthquake. A SOP was
established through a systemic literature review, action research, and two years of data collection.
Despite the limited time and resources inherent to a disaster situation, it is necessary to develop
an SOP for psychiatric service after an earthquake in order to assist the high number of survivors
suffering from subsequent psychiatric impairment.

Keywords: Disaster-Related Psychological Screening Test (DRPST), earthquake,

post-traumatic stress disorder (PTSD), standard operation procedure (SOP)

The devastating Chi-Chi earthquake, with its epicentre near the Chi-Chi Township
of Nantou County, Taiwan, measured 7.3 on the Richter scale and struck in the early
morning of 21 September 1999 (9/21) (Chou et al., 2007). Earthquakes were re­
sponsible for several devastating natural disasters in the twentieth and twenty-first
centuries (Chou et al., 2003). In 2004, a catastrophic earthquake (9.0 on the Richter
scale) in the Indian Ocean triggered a tsunami that resulted in the deaths of hun­
dreds of thousands of people in South and Southeast Asia (van Griensven et al.,
2006; Chou et al., 2007). In 2008, an earthquake in Szechwan, China, highlighted
the importance of disaster psychiatry.
  In comparison to hurricanes and floods, the occurrence of an earthquake is harder
to predict. Furthermore, aftershocks often cause survivors to re-experience the
traumatic event. In addition, earthquakes frequently cause more deaths and severe
injuries than other types of natural disaster (PAHO, 1981), and more time is re­
quired for the rescue of survivors of earthquakes and for the reconstruction of their
lives (Alexander, 1991). The damage caused by an earthquake can be extensive and
severe, and its effects often persist long after the event (Chou et al., 2004a, 2007).
  Following the 1999 Chi-Chi earthquake, the research team planned psychologi­
cal rehabilitation programmes for Yu-Chi Township. Yu-Chi was near the epicentre

Disasters, 2011, 35(3): 587−605. © 2011 The Author(s). Disasters © Overseas Development Institute, 2011
Published by Blackwell Publishing, 9600 Garsington Road, Oxford, OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA
588  Chao-yueh Su et al.

of the earthquake, providing the team with an opportunity to study the impact of
a natural disaster on survivors, both in general and with a focus on the Taiwanese
population (Chou et al., 2005).
  The human impact of a mass disaster is a composite of two elements: the cata­
strophic event itself; and the vulnerability of those people affected by the event
(Sapir, 1993). Studies focused on the survivors of the Chi-Chi earthquake found evi­
dence of psychological sequelae, including post-traumatic stress disorder (PTSD),
major depressive disorder, sleep disorder, anxiety, and substance abuse (Chen et al.,
2001; Chang et al, 2002; Hsu et al, 2002; Kuo et al, 2003; Yang et al, 2003; Chou
et al., 2004a, 2004b, 2005, 2007; Lai et al, 2004; Liu et al., 2006; Wu et al, 2006;
Tsai et al., 2007). The quality of life of survivors who develop psychiatric illnesses
or impairments is poorer than it is among those without a psychiatric illness (Chou
et al., 2004b; Wu et al, 2006; Tsai et al., 2007). In addition, rescue workers (such
as fire-fighters, nurses and soldiers) may develop physical or mental impairments
(Liao et al., 2002; Shih et al., 2002; Yeh et al., 2002; Chang et al., 2008).
  The researchers used PubMed ( to search
for Chi-Chi earthquake-related papers published between January 2001 and June
2009. Table 1 summarises all of the Chi-Chi earthquake papers related to psychiatry.
  It is difficult to reconstruct an individual’s life after a disaster. The Sphere Project2
and Inter-Agency Standing Committee have provided multi-sectoral guidelines to
mange such situations (IASC, 2007). Strong inter-relationships among social, mental
and physical aspects of health are commonly ignored in the rush to organise and
provide health care (IASC, 2007). This paper focuses primarily on mental reha­
bilitation. Therefore, it attempts to offer an integrated step-by-step screening and
reconstruction procedure for psychiatric aspects of rehabilitation.
  No extensive, systemic research programmes for post-disaster psychiatric services
existed in Taiwan or China prior to the Chi-Chi earthquake. While the authors
recognise the importance of mental health, understanding it is not the same as valu­
ing it. There is a wide gap between knowledge and action. Rehabilitation efforts
should concentrate not only on severe mental illnesses (SMIs) but also on emotional
disturbances and personality traits or disorders. When facing stress, frustration or
traumatic events (such as risk factors or deprivation of internal or external resources),
individuals become vulnerable to psychiatric impairment and disease. Other fac­
tors that tend to increase individuals’ vulnerability to psychiatric problems include
brain damage, heredity, personality traits, life events, and social interactions (Krause,
1987; Ursano, Kao and Fullerton, 1992). Consequently, multiple risk factors con­
stitute a network that results in psychiatric illness. An individual might reach a
sub-threshold of psychiatric illness and then develop the illness due to the decreas­
ing availability of resources, the accumulation of risk factors, or a major stressful
event. Furthermore, unresolved sub-clinical psychiatric symptoms caused by a dis­
aster might increase survivors’ sensitivity to future stresses (Heim and Nemeroff,
2001). Post-disaster survivors need, therefore, specific, systemic evaluation and
management. Some studies have shown that trauma increases help-seeking, which
Table 1 Summary of Chi-Chi earthquake papers related to psychiatry (PubMed search, January 2001–June 2009)

Author(s) Year Study period Subjects Purpose Method Conclusion

published after earthquake

Chen C.C. et al. 2001 Within 1 month 525 residents Screening for psychiatric morbidity Purposeful sampling 11% of the subjects reported having
and post-traumatic symptoms among thoughts of death or ideas of suicide.
survivors in the early stage 89.9% of respondents had psycho-
logical impairment.

Chen C.H. et al. 2001 Within 2 years 210 residents The Chinese version of the Davidson Translation, back-translation and Sensitivity of the instrument was 0.9,
Trauma Scale, a practice test for concurrent validity specificity was 0.81, positive likeli-
validation hood ratio was 4.74, and negative
likelihood ratio was 0.12.

Chang et al. 2002 6 months later 171 pregnant Psychiatric morbidity and pregnancy Purposeful sampling The prevalence of minor psychiatric
residents outcome in a disaster area. morbidity (MPM) was 29.2%.

Hsu et al. 2002 6 weeks later 323 student PTSD among adolescent earthquake Purposeful sampling Of 323 students, 21.7% had PTSD.
residents victims in Taiwan Being physically injured and experi-
encing the death of a close family
member with whom they had lived
were the two major risk factors.

Liao et al. 2002 2 months later 1,104 rescue Association of psychological distress Purposeful sampling Prevalence of general psychological
workers serv- with psychological factors in rescue distress is high among rescue work-
ing in the area workers ers. Personality traits and pre-disaster
hit by the life adjustment had a dominant
earthquake predictive power for psychological

Lin et al. 2002 1 year later 368 residents Geriatric survivors Purposeful sampling Lower quality of life in physical
(268 residents capacity, psychological well-being,
≥ 65 years old) and environment 12 months after
the earthquake when compared to
assessment prior to the earthquake.
The establishment of a standard operation procedure for psychiatric service after an earthquake

Shih et al. 2002 Within 1 year 46 nurses who The impact of the 9-21 earthquake Purposeful sampling The rescue experience helped to
worked in a experiences on Taiwanese nurses as strengthen most Taiwanese nurses’
hospital in the rescuers professional competency.

Yeh et al. 2002 Within 16 days 187 young, Characteristics of acute stress symp- Purposeful sampling Significant inverse correlation was
Chao-yueh Su et al.

male military toms and nitric oxide concentration observed between the severity of
personnel in young rescue workers in Taiwan stress symptoms and the plasma
who served concentration of nitric oxide in
as rescue rescue workers.

Chang et al. 2003 5 months later 84 male Post-traumatic distress and coping Purposeful sampling 16.7% and 21.4% prevalence of
fire-fighters strategies among rescue workers general psychiatric morbidity and
post-traumatic morbidity.

Chou et al. 2003 21 months later 461 residents Establishment of a disaster-related Population survey The DRPST, which was administered
psychological screening test in phase 1 of this two-phase study,
may be used for effective and rapid
screening for PTSD and MDE after an

Kuo et al. 2003 2 months later 120 bereaved To investigate the prevalence of Purposeful sampling PTSD: 37%; major depressive disorder:
survivors psychiatric disorders and risk factors 16%.
for PTSD and major depressive disor-
der among bereaved survivors

Yang et al. 2003 3 months later 663 victims To investigate the psychiatric morbid- Purposeful sampling PTSD: 11.3%; partial PTSD: 32.0%.
ity and post-traumatic symptoms
among earthquake victims in primary
care clinics

Chou et al. 2004a 21–24 months 461 residents To investigate quality of life and Purposeful sampling The prevalence of varied psychiatric
related risk factors in Taiwanese disorders in earthquake survivors
earthquake survivors with different ranged from 3.3–18%.
psychiatric disorders

Chou et al. 2004b 4–6 months 4,223 To investigate the relationship Purposeful sampling PTSD: 7.6%; suspected PTSD: 26.7%.
residents between quality of life and Worse quality of life in psychiatric
psychiatric impairment impairment patients.
Guo et al. 2004 1 month 252 rescue To investigate the prevalence of Purposeful sampling The prevalence of PTSD among
workers PTSD among professional and non- professional and non-professional
professional rescue workers involved rescuers were 19.8% and 31.8%.
in the 1999 Chi-Chi earthquake Disaster rescue work is associated
with a high level of stress, even
among highly trained professionals.
This work may lead therefore to
mental health problems.

Lai et al. 2004 10 months 252 residents Full and partial PTSD among earth- Randomly selected from two rural The prevalence rates for PTSD (n = 26)
quake survivors in rural Taiwan communities and sub-threshold post-traumatic
stress syndrome (PTSS) (n = 48) were
10.3% and 19.0%, respectively.

Chou et al. 2005 4–6 months 442 residents To assess the development of psychi- Population survey Females had significantly higher
atric disorders among residents post rates of most psychiatric disorders in
earthquake comparison to males.

Yang et al. 2005 During a 7- year – To examine time trends of increased Time-series analysis The mean monthly suicide rate for
period suicide rates earthquake victims was higher,
indicating the need for strengthened
psychiatric services in the first year
after a major disaster.

Seplaki et al. 2006 Before and after the 1,160 older To investigate variability in resilience Longitudinal survey with interviews Persons of low socioeconomic status,
earthquake individuals to depressive symptoms in the socially isolated individuals, and
aftermath of the 1999 earthquake women reported higher levels of
depressive symptoms than their
respective counterparts, as did persons
who experienced damage to their
homes. The psychological effects of
damage were strongest among those
aged between 54 and 70 years.

Wu et al. 2006 33–36 months 405 residents To investigate quality of life and Population survey The prevalence range for psychiatric
related risk factors in earthquake disorders in the earthquake survivors
survivors diagnosed with different was 0.2–7.2%. The persistence of
psychiatric disorders long-term economic problems was
one of many important factors affect-
ing quality of life.
The establishment of a standard operation procedure for psychiatric service after an earthquake

Chen et al. 2007 2 years later 6,412 earth- To examine the prevalence and risk Purposeful sampling The estimated rates of PTSD caseness
quake survivors factors of post-traumatic stress and psychiatric morbidity were 20.9%
whose houses symptoms and psychiatric morbidity and 39.8%, respectively. Psychiatric
were destroyed morbidity occurred mainly in survi-
vors who were female, older, with a
Chao-yueh Su et al.

low education level, and currently

living in a prefabricated house. The
risk factors for PTSD caseness were
female sex, currently living in a pre-
fabricated house, low education
level, and experience of complete
destruction of property.

Chou et al. 2007 6 months, 2 years 442, 461 and To survey the dynamic population for Population survey PTSD decreased significantly three
and 3 years later— 405 residents the risk factors of PTSD and major years later. However, suicidal ten-
total three times depression, as well as the prevalence dency and drug abuse/ dependence
of different psychiatric disorders six increased significantly.
months, two years and three years
after the earthquake

Kuo et al. 2007 1 year later 272 victims To investigate the incidence of PTSD Purposeful sampling Post-traumatic symptoms and psy-
from temporary among and the psychological health chological problems were more
housing units status of earthquake victims one year prevalent among women (22.2% and
after the event 64%, respectively) than among men
(9.2% and 47.9%, respectively).

Tsai et al. 2007 3 years later 1,756 To evaluate prospectively the rela- Fixed cohort follow-up Three years after the earthquake, the
respondents tionship between the clinical course estimated rate of post-traumatic stress
of post-traumatic stress symptoms symptoms had declined, and the
and quality of life quality of life of the survivors varied
according to how their post-traumatic
stress symptoms had progressed.

Chang et al. 2008 – 193 fire- To investigate the modification effects Purposeful sampling Older age and longer job experiences
fighters of coping strategies on the relation- (more than three years) were associ-
ship between rescue effort and ated with both general psychiatric
psychiatric morbidity in earthquake and post-traumatic morbidities.
rescue workers
The establishment of a standard operation procedure for psychiatric service after an earthquake 593

suggests that active screening and long-term psychiatric services are helpful for
survivor populations. In addition, a 2008 report offered some recommendations for
improving the psychiatric services delivered in a tertiary hospital (Humayun, 2008).
Yet a systemic and effective method of offering psychiatric services post earthquake
was not established. Hence, the goal of the current project is to present information
on the design and creation of a SOP for psychiatric service after an earthquake.

1. Instrument
A) Disaster-Related Psychological Screening Test (DRPST)
Immediately following a disaster, it is important to evaluate the damage and to
administer properly designed questionnaires to screen for mental symptoms among the
survivors. Moreover, the identification of at-risk groups may be facilitated by simple
screening instruments designed to detect significant emotional stress (Somasundaram
and van de Put, 2006).
  Five psychiatrists and two public health professionals designed the DRPST to
collect background information from residents and to determine their psychological
symptoms. Sleep disorders and anxiety disorders were included in the draft DRPST
until the researchers discovered that their psychiatric symptoms had a high preva­
lence and were non-specific for further evaluation. Although the symptoms of these
two disorders had been screened, they were not good indicators of high-risk groups.
The high sensitivity and low specificity of the original DRPST resulted in a poor
positive predictive value (PPV). The main measure includes 17 PTSD items and
nine major depressive episode (MDE) items that were created based on DSM-IV-
defined3 disaster-related psychiatric disorders.
  The questionnaires were designed to take account of the local language dialect
(Chou et al., 2003, 2004a).
  Most of the earthquake survivors still suffered the impacts of the earthquake and
they may have lacked patience due to a stress-induced reaction. As a result, they may
have refused to be screened if there were too many items on the questionnaires.
  It was necessary, though, for the psychiatric research team to identify quickly the
potential cases. Hence it reduced the number of items and retained the validity of
the questionnaires. Best subset regression analysis and the receiver operating char­
acteristics curve were utilised to select a subset of items and cut-off points for the
DRPST (Chou et al., 2003). Thus, the DRPST (still based on DSM-IV symptoms)
includes a seven-symptom scale for selecting probable PTSD screening and a three-
symptom scale for selecting probable major depression screening. Scores of four or more
on the PTSD scale were used to define a group of survivors with probable PTSD,
and scores of two or more on the major depression scale were used to define a
group of survivors with probable major depression (Chou et al., 2003). Compared to
the Mini-International Neuropsychiatric Interview in a population similar to that
594  Chao-yueh Su et al.

used in the present study, sensitivity was 76.1 per cent, specificity was 99.8 per cent,
the PPV was 97.2 per cent, and the negative predictive value (NPV) was 97.4 per
cent for PTSD. For major depressive episode, sensitivity was 92.1 per cent, specifi­
city was 98.3 per cent, the PPV was 83.3 per cent, and the NPV was 99.3 per cent
(Chou et al., 2003).

B) Disaster-Related Psychological Screening Test-Revised (DRPST-R)

Two years later, the psychiatric rescue team designed a questionnaire (Part I of the
DRPST-R) for long-term follow-up of earthquake survivors. It has been validated
as a measure of risk factors for psychiatric illness (Chou et al., 2003, 2004a, 2004b).
The questionnaire comprised seven sections (33 items): (1) bodily injury and phys­
ical illness; (2) financial problems after the earthquake, such as individual financial
loss, prominent financial loss immediately after the earthquake, or loss of family
income; (3) impact of family loss or injury; (4) change in social network; (5) change
in support system; (6) hardship caused by environmental change; and (7) change in
dietary habits (Tsai et al., 2007).
  Part II of the DRPST-R contained the demographic data and the screening items
of the DRPST. However, the team made some revisions in order to permit wider
application of items of major depression (additional items).

2. Respondents and clinical workers

This study examined 4,223 respondents living near the epicentre of the Chi-Chi
earthquake within six months of the event (see Chou et al., 2004a). Members of
this group provided useful information for the patient cohort and proved valuable
for long-term follow-up studies on the prevalence of psychiatric illness after natu­
ral disasters (Chou et al., 2003). Three years later, in 2004, the psychiatric research
team continued to track 1,756 respondents (Tsai et al., 2007). The staff included 15
psychiatrists, five psychiatric nurses, two psychologists, two social workers, and two
public health scholars, all of whom were volunteers. It included as well six short-
term training assistants whose salaries were paid by the Department of Health,
Republic of China.

3. Procedures
This is an empirical and action study. A total of 4,223 respondents were screened
between one week and six months of the earthquake. The adjusted response rate
was 60.3 per cent in the first population survey conducted between four and six
months (0.5 years) after the earthquake (Chou et al., 2004a); 1,756 of these respond­
ents were included in the follow-up conducted 33–36 months (three years) after the
earthquake (Tsai et al., 2007). Of the group of 2,467 (4,223 - 1,756) participants who
were not part of the follow-up, 1.4 per cent died, 6.1 per cent moved away, 55.4 per
cent lived outside of the township because of employment, 1.2 per cent lived out­
side of the township for educational purposes, 30.4 per cent refused to participate in
The establishment of a standard operation procedure for psychiatric service after an earthquake 595

the study, and 5.5 per cent could not be found after three visits to their homes.
Since the catastrophic earthquake affected millions of people who lived near the
epicentre, there was insufficient psychiatric manpower to screen and manage all of
the victims. Regular psychiatric service was offered in a fixed place at the outset.
However, little service (only eight cases in two months) was provided due to passive
attitudes, a lack of knowledge of psychiatric illness, and social stigma. The service
model was changed to home-visit treatment (door-knocking) after discussion at a
meeting of experts. Even though this method was expensive in terms of human
resources, home-visit (door-knocking) treatments increased the reception of psy­
chiatric treatment. Continuous home-visit treatment is the best way to ensure that
people with mental illness receive medication and treatment (Lin et al, 2004; Tsai
et al., 2004). A flexible, proactive, and assertive approach to service delivery during
the crisis situation helps to make certain that care needs are met (McMurray and
Steiner, 2000). Repeated discussions among team members and literature reviews
were encouraged. Before the home-visit interviews, assistants made telephone calls
to the respondents. Psychiatric health education was held during traditional festival
activities to establish a better rapport and to decrease the stigma associated with men­
tal disorders. All of these efforts helped the psychiatric evaluations and treatment
programmes to proceed smoothly.
  The team, responsible for Yu-Chi Township, located near the epicentre, thus
attempted to develop a rapid and valid tool and an SOP to identify the survivors
with psychiatric impairments or diseases. The clinical difficulties were discussed in
a meeting, and a proper management process was established within one year. The
team analysed the data and questions and then produced a draft SOP and clinical
guidelines based on expert consensus. When the provisions of these guidelines were
completed in 2005, scholars and professionals were invited to evaluate them. Finally,
two years later, the researchers revised the SOP, DRPST, and clinical guidelines.

1. Demographic data and grouping
Of the 4,223 respondents, 1,448 (34.3 per cent) exhibited moderate-to-severe psychi­
atric impairment. The respondents were stratified into four psychiatric impairment
groups, which were determined according to DRPST score: healthy (n = 952; 22.5
per cent); mild (n = 1,823; 43.2 per cent); moderate (n = 1,126; 26.7 per cent); and
severe (n = 322; 7.6 per cent). The proportion of male respondents was higher for
the healthy group (59.1 per cent) than for the psychiatrically impaired group (36.3–
50.2 per cent) (Chou et al., 2004a). The team followed up with 1,756 of the 4,223
respondents three years later. The average age of the 1,756 respondents was 54.5 ± 16.7
(range: 16–98); roughly 54.4 per cent of the respondents were women (male: 801;
female: 955). The education level was predominantly primary school or lower (64.5 per
cent). At six months and three years after the earthquake, the estimated rates of post-
traumatic stress symptoms were 23.8 and 4.4 per cent, respectively (Tsai et al., 2007).
596  Chao-yueh Su et al.

Figure 1 Flowchart of psychiatric team intervention after an earthquake

2. The establishment of an SOP

The Chi-Chi earthquake demonstrated that the Emergency Operation Centre (EOC)
should be set up within the shortest possible amount of time (between one and
eight hours). The EOC should report the updated situation to the central government,
as the scale of the EOC depends on the disaster’s degree of emergency. Within 24–48
hours, the EOC should assess the actual damage situation and coordinate ‘battle
resources’ (such as manpower and equipment) according to the functions of the sup­
porting teams and real needs in the disaster area(s). Multiple rescue teams (such as
the administrative team, the public health and medical team, and the engineering
The establishment of a standard operation procedure for psychiatric service after an earthquake 597

Figure 1 Cont.

and rescue-worker team) should be involved during the urgent initial stage. An
emergency management system should be established to intervene effectively imme­
diately after a disaster. Systemic mental rehabilitation should be performed one to
three months after the disaster, as detailed in Figure 1.

3. Content of the clinical guidelines

The team members met regularly to discuss and prepare content for the clinical guide­
lines. This content was as follows: (1) a historical review of the theory and thera­
peutic model of PTSD, including earthquake-related data; (2) the epidemiology of
earthquake-related psychiatric illness; (3) the SOP for mental rehabilitation at succes­
sive stages after an earthquake; (4) a training programme for mental health profes­
sionals; (5) the validity, reliability, application and introduction of appropriate screening
598  Chao-yueh Su et al.

measures; (6) preparation of the treatment programme; (7) management of resist­

ance in disaster survivors that may occur during treatment for mental rehabilitation
(such as inviting and encouraging survivor feedback and responding to questions
that address their concerns and fears); (8) employment of a different treatment model
when deemed necessary by team members; (9) sharing of experiences among team
members working on different areas of survivor treatment; (10) risk factors in post-
disaster survivors with continuing psychiatric disorders; (11) suicide prevention tactics
for survivors; (12) the mental health of the rescue staff; (13) the design and applica­
tion of psycho-education; and (14) the memo and appendix.

1. Early detection and intervention after the disaster
In general, an integrated rehabilitation programme is a balanced initiative with the pur­
pose of helping all members of the community recover via different plans, activities
and resources. Essential community resources that are likely to be helpful in respond­
ing to a disaster (such as schools, hospitals, places of worship, shelters, community
halls and local service groups) should be well-known (Somasundaram and van de
Put, 2006). These resources should be formulated and integrated to achieve maxi­
mum effectiveness. If there are no special conditions, a localised rehabilitation pro­
gramme should be considered during the recovery period. It is necessary to intervene
in a step-by-step manner and to manage subjects systematically (see Figure 1).

2. Model of psychiatric intervention after an earthquake

Although people are sympathetic, they succumb easily to the ‘blind swarming
phenomenon’. Consequently, relief resources often are allocated inefficiently and
ineffectively. For example, the television stations gave spot coverage to some disaster
areas. These ‘Star Disaster Areas’ received an overwhelming amount of resources,
whereas other unknown disaster areas lacked resources. The same situation occurred
with the mental health survey and mental filtration. The coordinated engagement of
various ‘charitable organisations’ (based on schedule and need) is important because
it prevents the administration of repeated questionnaires. In the absence of these
charitable organisations, people may become distressed and resistant to systematic
mental-rebuild in the post-disaster stage. Another important factor is based on the
notion that stressed people cannot address rationally some questions due to anger after
an earthquake.
  To establish a good relationship between the psychiatric team and the patients
during long-term mental rehabilitation and treatment, an effective interposition
strategy (that is, one planned in advance) that avoids patient antipathy due to repeated
evaluation should be planned. It is important to recognise the mental feedback of
disaster victims and to use this information to generate a strategy for establishing
personal relationships. Strategies include learning about local life and earning the
trust of the people involved. Such techniques can facilitate the post-earthquake mental
The establishment of a standard operation procedure for psychiatric service after an earthquake 599

rehabilitation process. For example, although people in a disaster area frequently

suffer from acute stress reactions (such as sleeplessness, anger or panic), emergency
medical stations set up within 24 hours of a disaster typically neglect psychiatric
treatment. Instead, they focus on providing life resources, medical or surgical treat­
ment, and quarantine systems to prevent the spread of infectious diseases (Chou,
2003). In the urgent period (within one week), however, the psychiatric team can
provide care and create an intervention treatment strategy (Chou, F.H. et al., 2003).
For example, the proportion of mental disorders can be assessed as a reference for
future psychiatric human resource planning. Rather than concentrating on individ­
ual ‘treatment’, it would be more prudent to use public mental health promotional
activities as well as community approaches (Somasundaram and van de Put, 2006).
These steps provide the foundation of a good relationship for future long-term
mental rehabilitation (Chou, 2003). Another important aspect of this process is
establishing a good rapport with survivors. This type of interaction will enable fur­
ther mental rehabilitation.

3. Screening for psychiatric illness and offering mental services

Enhancing the ability to screen for and to manage the symptoms of PTSD, major
depressive disorder and panic disorder one month after screening will help to prevent
the chaos associated with treating a large number of patients. At this time, a two-
stage screening test is a good option when insufficient psychiatric specialists are
available. Questionnaires that are overly specific are not well-suited to the first screen­
ing step. Using local languages (such as Taiwanese) also decreases the difficulty of
approaching the victims. A rapid screening questionnaire should be designed for
non-psychiatric laypersons screening a large number of patients in a short period of
time. The team screened 1,448 respondents (34.3 per cent of all respondents) with
moderate to severe mental disorders (Chou et al., 2004a). Providing training and
support to mental health workers in the affected communities is an effective method
of reaching disaster victims (Somasundaram and van de Put, 1999).
  Given the resource limitations that exist at the beginning of an earthquake re­
sponse (especially in terms of psychiatric manpower), the research team selected
subjects with higher scores as positive cases on the DRPST for phase 1 screening of
earthquake victims. In the long-term follow-up stage, however, it selected appro­
priate lower cut-off points to screen subjects and provide information that was
useful both for the patient cohort and the long-term follow-up study of the preva­
lence of psychiatric illness. If respondents required further psychotherapy, medication
or other psychiatric treatment, they were referred to psychiatrists. If they refused
the referral, the team offered toll-free telephone counselling and arranged home
visits by the local health department. Approximately 130 respondents (some 10 per
cent of respondents with moderate-to-severe psychiatric illness) received multiple
medication treatments. Only 84 respondents (5.8 per cent of respondents with
moderate-to-severe psychiatric illness) received continuous psychiatric treatment
(Lin et al., 2004). These findings reveal the importance of active follow-up in light
of the resistant attitude among the respondents.
600  Chao-yueh Su et al.

  After the acute stage, some people can recover from anxiety and panic. However,
some people with different degrees of mental disorder require continuous psychi­
atric intervention. The prevalence rates of mental disorder, especially PTSD and
major depressive disorder, increase in the first two years after an earthquake (Chou, al., 2003, 2004b). The prevalence rates of psychiatric illness decrease in the
third year after an earthquake, but the prevalence rates of suicidal tendency and
sedative dependence/abuse continue to rise (Chou, F.H. et al., 2003, 2004b; Wu et
al., 2006). For these reasons, the team continued home-visit treatment throughout
the first two years. In addition, it encouraged local mental health clinics to follow
up with high suicide risk respondents during the third year.
  Rescue efforts should occur within 24 hours of a disaster. The first job is to save
the victims’ lives within the critical three-day period. The establishment of an emer­
gency medical station to provide physical, psychiatric and public heath epidemic
intervention and services needs to be completed within one week. With regard to
the psychiatric aspect, one additional month is needed to screen for psychiatric
symptoms and illnesses, such as acute stress disorder. After three to six months,
chronic type and delayed onset PTSD should be detected (DSM-IV-TR). Given
that the team found that the prevalence of PTSD decreased after three years, this
study suggests that the total follow-up period last three years.

4. Necessity of post-disaster mental rehabilitation

Krause (1987) states that care should be taken during the interval between the initia­
tion and development of stress. Furthermore, according to conservation of resources
(COR) theory (Hobfoll, 1989), resource loss is an important factor in individual
stress and physical and mental health. Traumatic events result from the complicated
interaction of an individual’s history, real life, future expectations and reinforcing
biological factors (Ursano, Kao and Fullerton, 1992). For most individuals, the
imbalance of emotion, behaviour, way of thinking and biological factors is temporary.
Changes and impacts are durable and influential for some victims with psycho­
logical trauma (Perkonigg et al., 2000; Chou, F.H. et al., 2003). In fact, mental
rehabilitation is a crucial part of rebuilding their lives. Rehabilitation requires a
sound plan, and it is a long and difficult journey (Chou, F.H. et al., 2003). Different
treatments induce different results. In an earthquake, men and women frequently
suffer from psychiatric impairments or diseases. These individuals need care and
treatment. Designing a two-stage psychiatric screening questionnaire in which the
first stage is administered by non-professionals is an effective way to conserve limited
human resources. After a disaster, surveys of psychiatric impairment or diseases and
psychiatric illness enforcing factors are helpful for future recovery.

5. Important roles of joint alternative medicine and religion in the acute

stage of a disaster
In comparison to other resource needs, fewer psychiatric services for the sudden
loss of family members and assets were required after four weeks. Facing an unstable
The establishment of a standard operation procedure for psychiatric service after an earthquake 601

future and life-threatening situations also make immediate psychiatric services useless.
For example, some survivors with acute stress responses (such as insomnia, anxiety
or panic-like symptoms) refuse to take hypnotics or calmatives. These people fear
that they will be unable to escape another disaster if they take the medication (in
fact, some aftershocks of the Chi-Chi earthquake measured 6.8 on the Richter
scale). It seems as though some type of alternative therapy could be another method
of transient management in the chaotic stage immediately after the disaster. For
example, a rescue soldier complained about nightmares due to seeing and moving
a corpse. He thought that he could not fall asleep because of the ‘ghost’ around
him. He did not believe that any therapist or medication would help him, so a doc­
tor gave him a bottle of mineral water imbued with magical effects from Buddha.
The soldier could fall asleep quite easily after the doctor’s employment of the placebo
effect (Chou, F.H. et al., 2003). This traditional help-seeking behaviour and the
resulting help strategy must be understood on a cultural basis. Accommodations
must be made since more conventional methods of mental health intervention may
not meet with the same acceptance in different cultures (Somasundaram and van
de Put, 2006).
  Furthermore, holding religious rituals in the first three months after a disaster
can stabilise victims’ mental health. Such rituals provide another type of ‘group
therapy’. Except in the management of survivors with severe mental disorders, strict
use of traditional psychiatric medicine is unnecessary at this stage. Transient alter­
native therapies may decrease the incidence of disturbance among the survivors.
Religion often supports the helpless, especially post-disaster. Alternative approaches
may include establishing support groups for specific survivors as well as more un­
orthodox approaches, such as ‘inventing’ new rituals that help people deal with the
specific traumatic event(s) (van de Put and Eisenbruch, 2004). When a disaster occurs,
resources can be combined to assist the public and provide mental health education
activities, especially for those who resist psychiatric treatment.

6. Integration of all resources

According to COR theory (Hobfoll, 1989), resource loss is an important determinant
of individual stress and physical and mental health. The impairments of survivors
are not only a function of the severity of exposure to mass trauma, but also are con­
structed out of the social and economic circumstances of everyday living (Morrow,
1999; Hutton and Haque, 2004). There is evidence to suggest that underlying eco­
nomic and social relationships can increase human vulnerability not only during a
disaster, but also in the immediate aftermath and in the long-term post-disaster
environment (Lima et al., 1991; Chou et al., 2004c).
  The rescue and rebuilding of the disaster area requires a multidisciplinary effort.
Problems may include: (1) an ineffective command centre; (2) poor communication;
(3) a lack of cooperation between the civil government and the military; (4) delayed
pre-hospital care; (5) overloading of hospitals beyond capacity; (6) inadequate staff­
ing; and (7) mismanaged public health measures (Chan et al., 2006).
602  Chao-yueh Su et al.

  This period of rescue and recovery was difficult for the research team, as there
was limited local experience and no clinical guidelines for dealing with such a
situation. Due to ethical concerns, a case control study design could not be used to
compare the efficacy of various procedures. Clinical services were offered before
the team began the study. Clinical experience provided the team with many valu­
able observations. For example, repeated questionnaires performed by different
rescue teams made people resist and refuse further evaluation and referrals. Long-
term tracking of these people was hard because of the stigma of such variables as
psychiatric illness and moving away. In addition, it was hard to integrate all aspects
of the resources in a way that would allow them to be managed effectively.

There are still many undetected factors that must be overcome when facing new
challenges in the twenty-first century. Although the types of disasters may vary, it
is vital to train a sufficient number of specialists and to create an SOP for reducing
disturbing conditions when any disaster occurs. The research team humbly offers
its experience and psychiatric intervention model to those who need it, although it
hopes that there will be no catastrophic disasters in the future.

The authors thank the staff of the Kai-Suan psychiatric hospital, the teachers and
postgraduate students at the Institute of Public Health at the National Yang-Ming
University, and assistants Meng-Jun Pan, Shih-Pei Shen and Shih-Shih Chao. The
study was supported by grants from the National Science Council (NSC 92-2625-
Z-280-001 and NSC 93-2625-Z-010-001).

Wen-Kuo Lin, Department of Community Psychiatry, Kai-Suan Psychiatric Hospital
130, Kai-Suan 2nd Rd, Lingya district, Kaohsiung, Taiwan. Telephone: +886-7-7513171-
2232; fax: +886-7-5373299; e-mail:

Chao-yueh Su, Med is Assistant Professor at the Department of Nursing, I-Shiou University,
Taiwan; Frank Huang-Chih Chou, MD, MS, PhD is Deputy Superintendent at the Department
of Community Psychiatry, Kai-Suan Psychiatric Hospital, and Adjunct Associate Professor at the
Department of Nursing, Meiho University, Taiwan; Kuan-Yi Tsai, MD, MS is Attending Physician
at the Department of Community Psychiatry, Kai-Suan Psychiatric Hospital, Taiwan; and Wen-Kuo
Lin, MD is Attending Physician at the Department of Community Psychiatry, Kai-Suan Psychiatric
Hospital, Taiwan.
The establishment of a standard operation procedure for psychiatric service after an earthquake 603


Alexander, D.E. (1991) ‘Nature disasters: a framework for research and teaching’. Disasters. 15(3).
pp. 209–226.
Chan, Y.F. et al. (2006) ‘Disaster management following the Chi-Chi earthquake in Taiwan’. Pre-
hospital Disaster Medicine. 21(3). pp. 196–202.
Chang, C.M. et al. (2003) ‘Posttraumatic distress and coping strategies among rescue workers after
an earthquake’. Journal of Nervous and Mental Disease. 191(6). pp. 391–398.
Chang, C.M., L.C. Lee, K.M. Connor, J.R. Davidson and T.J. Lai (2008) ‘Modification effects of coping
on post-traumatic morbidity among earthquake rescuers’. Psychiatry Research. 158(2). pp. 164–171.
Chang, H.L., T.C. Chang, T.Y. Lin and S.S. Kuo (2002) ‘Psychiatric morbidity and pregnancy
outcome in a disaster area of Taiwan 921 earthquake’. Psychiatry and Clinical Neuroscience. 56(2).
pp. 139–144.
Chen, C.H., S.K. Lin, H.S. Tang, W.W. Shen and M.L. Lu (2001) ‘The Chinese version of the
Davidson Trauma Scale: a practice test for validation’. Psychiatry and Clinical Neuroscience. 55(5).
pp. 493–499.
Chen, C.C. et al. (2001) ‘Psychiatric morbidity and post-traumatic symptoms among survivors in
the early stage following the 1999 earthquake in Taiwan’. Psychiatry Research. 105(1–2). pp. 13–22.
Chen, C.H. et al. (2007) ‘Long-term psychological outcome of 1999 Taiwan earthquake survivors:
a survey of a high-risk sample with property damage’. Comprehensive Psychiatry. 48(3). pp. 269–275.
Chou, F.H. et al. (2003) ‘Establishment of a disaster-related psychological screening test’. The Australian
and New Zealand Journal of Psychiatry. 37(1). pp. 97–103.
Chou, F.H. et al. (2004a) ‘Survey of quality of life and related risk factors for a Taiwanese village
population 21 months after an earthquake’. The Australian and New Zealand Journal of Psychiatry.
38(5). pp. 358–364.
Chou, F.H. et al. (2004b) ‘The relationship between quality of life and psychiatric impairment for
a Taiwanese community post earthquake’. Quality of Life Research. 13(6). pp. 1089–1097.
Chou, F.H. et al. (2005) ‘Survey of psychiatric disorders in a Taiwanese village population half a
year after a major earthquake’. Journal of the Formosan Medical Association. 104(5). pp. 308–317.
Chou, F.H. et al. (2007) ‘Epidemiologic psychiatric studies on post-disaster impact among Chi-Chi
earthquake survivors in Yu-Chi, Taiwan’. Psychiatry and Clinical Neurosciences. 61(4). pp. 370–378.
Chou, Y.J. (2004) ‘Who is at risk of death in an earthquake?’ American Journal of Epidemiology. 160(7).
pp. 688–695.
Guo, Y.J. et al. (2004) ‘Posttraumatic stress disorder among professional and non-professional rescuers
involved in an earthquake in Taiwan’. Psychiatry Research. 127(1). pp. 35–41.
Heim, C. and C.B. Nemeroff (2001) ‘The role of childhood trauma in the neurobiology of mood
and anxiety disorders: preclinical and clinical studies’. Biological Psychiatry. 49(12). pp. 1023–1039.
Hobfoll, S.E. (1989) ‘Conservation of resources. A new attempt at conceptualizing stress’. The American
Psychologist. 44(3). pp. 513–524.
Hsu, C.C., M.Y. Chong, P. Yang and C.F. Yen (2002) ‘Posttraumatic stress disorder among adolescent
earthquake victims in Taiwan’. Journal of the American Academy of Child and Adolescent Psychiatry.
41(7). pp. 875–881.
Humayun, A. (2008) ‘South Asian earthquake: psychiatric experience in a tertiary hospital’. Eastern
Mediterranean Health Journal. 14(5). pp. 1205–1216.
604  Chao-yueh Su et al.

Hutton, D. and C.E. Haque (2004) ‘Human vulnerability, dislocation and resettlement: adaptation
processes of river-bank erosion-induced displacees in Bangladesh’. Disasters. 28(1). pp. 41–62.
IASC (Inter-Agency Standing Committee) (2007) IASC Guidelines on Mental Health and Psychosocial
Support in Emergency Settings. IASC, Geneva.
Krause, N. (1987) ‘Exploring the impact of a natural disaster on the health and psychological well-
being of older adults’. Journal of Human Stress. 13(2). pp. 61–69.
Kuo, C.J. et al. (2003) ‘Prevalence of psychiatric disorders among bereaved survivors of a disastrous
earthquake in Taiwan’. Psychiatric Services. 54(2). pp. 249–251.
Kuo, H.W., S.J. Wu, T.C. Ma, M.C. Chiu and S.Y. Chou (2007) ‘Posttraumatic symptoms were
worst among quake victims with injuries following the Chi-chi quake in Taiwan’. Journal of
Psycho­somatic Research. 62(4). pp. 495–500.
Lai, T.J., C.M. Chang, K.M. Connor, L.C. Lee and J.R. Davidson (2004) ‘Full and partial PTSD
among earthquake survivors in rural Taiwan’. Journal of Psychiatric Research. 38(3). pp. 313–322.
Liao, S.C. et al. (2002) ‘Association of psychological distress with psychological factors in rescue
workers within two months after a major earthquake’. Journal of the Formosan Medical Association.
101(3). pp. 169–176.
Lima, B.R., S. Pai, H. Santacruz and J. Lozano (1991) ‘Psychiatric disorders among poor victims fol­
lowing a major disaster: Armero, Colombia’. Journal of Nervous and Mental Disease. 179(7). pp. 420–427.
Lin, C.Y. et al. (2004) ‘Quality of life and severity of psychiatric symptoms in survivors of a major
earthquake’. Mid-Taiwan Journal of Medicine. 9(S1). pp. S9–S15. (Full text in Chinese with English
Lin, M.R. et al. (2002) ‘The impact of the Chi-Chi earthquake on quality of life among elderly
survivors in Taiwan—a before and after study’. Quality of Life Research. 11(4). pp. 379–388.
Liu, A. et al. (2006) ‘An epidemiologic study of posttraumatic stress disorder in flood victims in Hunan
China’. Canadian Journal of Psychiatry. 51(6). pp. 350–354.
McMurray, L. and W. Steiner (2000) ‘Natural disasters and service delivery to individuals with severe
mental illness—ice storm 1998’. Canadian Journal of Psychiatry. 45(4). pp. 383–385.
Morrow, B.H. (1999) ‘Identifying and mapping community vulnerability’. Disasters. 23(1). pp. 1–18.
PAHO (Pan American Health Organization) (1981) Emergency Health Management after Natural Disasters.
Scientific Publication No. 47. Office of Emergency Preparedness and Disaster Relief Coordina­
tion, PAHO, Washington, DC.
Perkonigg, A., R.C. Kessler, S. Storz and H.U. Wittchen (2000) ‘Traumatic events and post-traumatic
stress disorder in the community: prevalence, risk factors and comorbidity’. Acta Psychiatrica
Scandinavica. 101(1). pp. 46–59.
Sapir, D.G. (1993) ‘Natural and man-made disasters: the vulnerability of women-headed households
and children without families’. World Health Status Quarterly. 46(4). pp. 227–233.
Seplaki, C.L., N. Goldman, M. Weinstein and Y.H. Lin (2006) ‘Before and after the 1999 Chi-Chi
earthquake: traumatic events and depressive symptoms in an older population’. Social Science of
Medicine. 62(12). pp. 3121–3132.
Shih, F.J., Y.C. Liao, S.M. Chan, B.R. Duh and M.L. Gau (2002) ‘The impact of the 9-21 earthquake
experiences of Taiwanese nurses as rescuers’. Social Science of Medicine. 55(4). pp. 659–672.
Somasundaram, D.J. and W.A. van de Put (1999) ‘Mental health care in Cambodia’. Bulletin of the
World Health Organization. 77(3). pp. 275–277.
Somasundaram, D.J. and W.A. van de Put (2006) ‘Management of trauma in special populations
after a disaster’. The Journal of Clinical Psychiatry. 67(2). pp. 64–73.
Tsai, K.Y. et al. (2004) ‘Association of psychiatric illness with quality of life among survivors of the
Chi-Chi earthquake’. Taiwanese Journal of Psychiatry. 18(2). pp. 108–118. (Full text in Chinese with
English abstract.)
The establishment of a standard operation procedure for psychiatric service after an earthquake 605

Tsai, K.Y. et al. (2007) ‘Three-year follow-up study on the relationship between posttraumatic stress
symptoms and quality of life among earthquake survivors in Yu-Chi, Taiwan’. Journal of Psychiatric
Research. 41(1–2). pp. 90–96.
Ursano, R.J., T. Kao and C.S. Fullerton (1992) ‘PTSD and meaning: structuring human chaos’.
Journal of Nervous and Mental Disease. 180(12). pp. 756–759.
van de Put, W.A. and M. Eisenbruch (2004) ‘Internally displaced Cambodians: healing trauma in
communities’. In K. Miller and L. Rasco (eds.) The Mental Health of Refugees: Ecologic Approaches to
Healing and Adaptation. Lawrence Erlbaum Associates, Inc., Mahwah, NJ. pp. 133–159.
van Griensven, F. et al. (2006) ‘Mental health problems among adults in tsunami-affected areas in
southern Thailand’. Journal of the American Medical Association. 296(5). pp. 537–548.
Wu, H.C. et al. (2006) ‘Survey of quality of life and related risk factors for a Taiwanese village
population 3 years post-earthquake’. The Australian and New Zealand Journal of Psychiatry. 40(4).
pp. 355–361.
Yang, Y.K. et al. (2003) ‘Psychiatric morbidity and posttraumatic symptoms among earthquake
victims in primary care clinics’. General Hospital of Psychiatry. 25(4). pp. 253–261.
Yang, C.H., S. Xirasagar, H.C. Chung, Y.T. Huang and H.C. Lin (2005) ‘Suicide trends following
the Taiwan earthquake of 1999: empirical evidence and policy implications’. Acta Psychiatrica
Scandinavica. 112(6). pp. 442–448.
Yeh, C.B., J.F. Leckman, F.J. Wan, I.S. Shiah and R.B. Lu (2002) ‘Characteristics of acute stress
symptoms and nitric oxide concentration in young rescue workers in Taiwan’. Psychiatry Research.
112(1). pp. 59–68.
Copyright of Disasters is the property of Wiley-Blackwell and its content may not be copied or emailed to
multiple sites or posted to a listserv without the copyright holder's express written permission. However, users
may print, download, or email articles for individual use.