Disaster Mental Health Primer: Key Principles, Issues and

Questions
NOTE: These materials represent highlights of the kinds of mental-health related information that might be beneficial in a disaster.
Because of their brevity, they do not provide an exhaustive, formal review or compilation of the wealth of available knowledge on
disaster mental health. This is a starting point. There are companion pieces that provide similar information for city, county and
state Public Health officials and as a general primer. Sources of additional information are listed at the end of this document.

The Impact Pyramid (The victim count only represents the tip of the iceberg.)

Individual victims
Families and social networks
Rescue workers, medical care providers, their families and social networks
Vulnerable populations and impacted businesses
Ordinary people and their communities

Guiding Principles (It is helpful to keep these points in mind when preparing for or responding to a
disaster.)
• No one who experiences a disaster is untouched by it.
• Most people pull together and function during and after a disaster, but their effectiveness is
diminished.
• Mental health concerns exist in most aspects of preparedness, response and recovery.
• Disaster stress and grief reactions are “normal responses to an abnormal situation.”
• Survivors respond to active, genuine interest and concern.
• Disaster mental health assistance is often more practical than psychological in nature (offering a
phone, distributing coffee, listening, encouraging, reassuring, comforting).
• Disaster relief assistance may be confusing to disaster survivors. They may experience frustration,
anger, and feelings of helplessness related to Federal, State, and non-profit agencies’ disaster
assistance programs. They may reject disaster assistance of all types.

Phases of a Disaster (General Principles. No precise, universal timeline exists. Responses vary by
disaster. These phases first were observed/described in natural disasters.)

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Disaster Mental Health Primer: Key Principles, Issues and Questions
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• Warning of Threat: Ranges from no advance notice (suicide bomber) to weeks (hurricane)
• Impact: Actual onset of disaster Varies. BT has fuzzy beginning/end; bombing is precise
• Rescue or Heroic: People watch out for, protect, even risk own safety to save strangers
• Remedy or Honeymoon: People initially pitch in and collaborate for the collective good
• Inventory: External resources begin to come online—people watch what goes where
• Disillusionment: Resource allocation often seen as too little too late, poorly distributed
• Reconstruction and Recovery: People move beyond self interests and start to rebuild

Factors That Determine the Stressfulness of a Disaster (Individual responses are a function of
the interplay of multiple factors.)

Features of the Disaster

Familiarity with the event Avoidability of the event
Suddenness of its onset Intensity of its impact
Course and duration of the event Degree to which it can be controlled

Community or Societal Factors

Previous level of community resources Community’s level of preparedness
Extent and nature of damage done Community’s experience with such an event
Consequent social/political unrest Availability of resources to rebuild

Characteristics of the Individuals Involved

Actual losses (and threat of loss) Previous experience with similar events
Level of background stress in one’s life Physical or psychological closeness to event
Effectiveness of one’s coping mechanisms Nature and extent of available social support

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Disaster Mental Health Primer: Key Principles, Issues and Questions
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Severity of Psychological Reaction After a Traumatic Event (Most people affected by a

traumatic event “recover” without external intervention.)

Potential Risk Groups (Certain individuals/groups are more vulnerable than others.)
• Age groups (Infants, children and seniors)
• Cultural and Ethnic Groups (immigrants, non-English speakers, undocumented aliens etc.)
• Low-visibility groups (homeless, mobility-impaired, unemployed, mentally-challenged etc.)
• People with Serious and Persistent Mental Illness
• People in Group Facilities (hospitals, nursing homes, prisons)
• Human Service, Healthcare and Disaster Relief Workers

Survivor’s Needs & Reactions (While people respond differently, there are common needs.)
• A concern for basic survival
• Grief over loss of loved ones and loss of valued/meaningful possessions
• Fear and anxiety about personal safety and physical safety of loved ones
• Sleep disturbances, often including nightmares and imagery from the disaster
• Concerns about relocation and the related isolation or crowded living conditions
• A need to talk, often repeatedly, about events and feelings associated with the disaster
• A need to feel one is a part of the community and its recovery efforts

Reactions that Signal Possible Need for Mental Health Referral (Many responses to trauma
are expected, but some require extra attention and concern.)
• Disorientation (dazed, memory loss, unable to give date/time or recall recent events…)
• Depression (pervasive feeling of hopelessness & despair, withdrawal from others…)
• Anxiety (constantly on edge, restless, obsessive fear of another disaster…)
• Mental Illness (hearing voices, seeing visions, delusional thinking…)
• Inability to care for self (not eating, bathing, changing clothing or handling daily life)
• Suicidal or homicidal thoughts or plans
• Problematic use of alcohol or drugs
• Domestic violence, child abuse or elder abuse

Common Disaster Worker Stress Reactions (See list in: “Disaster Mental Health for Responders:
Key Principles, Issues and Questions”)
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Disaster Mental Health Primer: Key Principles, Issues and Questions
(continued from previous page)

Stress Basics. (A quick review to help keep stress in perspective.) Stress is:
• Normal
• Necessary
• Productive and destructive
• Acute and delayed
• Cumulative
• Identifiable
• Preventable (Much stress is); Manageable (Most stress is)

Some of the Sources of Information Used in this Overview

Academic & Specialty Centers for Public Health Preparedness
(http://www.phppo.cdc.gov/owpp/cphp.asp)
American Psychiatric Association
(http://www.psych.org/)
National Center for Post Traumatic Stress Disorder
(http://www.ncptsd.org)
The National Child Traumatic Stress Network
(http://www.nctsnet.org/nccts/nav.do?pid=hom_main)
Uniformed Services University of the Health Sciences
(http://www.usuhs.mil/psy/traumaticstress/newcenter.html)
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services
Administration
(http://www.mentalhealth.samhsa.gov/publications/allpubs/ADM90-537/Default.asp)

For more information, visit www.bt.cdc.gov

or call CDC at 800-CDC-INFO (English and Spanish) or 888-232-6348 (TTY).

August 30, 2005 Page 4 of 4

 Guidelines in Disaster and Management
Situations
The mental health response to a disaster must be a well-coordinated effort that draws
on a variety of professionals, paraprofessionals, and volunteers who have been
prescreened and specially trained. In the immediate aftermath, the goal of mental
health intervention is to facilitate normal coping, treat those with immediate needs,
and begin to identify those at risk for psychiatric disorders in the ensuing weeks,
months, and years. Although mental health interventions have not been shown to
prevent psychiatric disorders once exposure to a traumatic event has occurred,
research continues to search for strategies that can mitigate harmful effects.
Management of the psychological effects of the disaster will continue long after the
impact.
Psychological First Aid (PFA) is an evidence-informed approach designed to reduce
distress in the immediate aftermath of a disaster and foster adaptive functioning and
coping. Major depression and PTSD can be disabling consequences of exposure to
disaster among those of any age group and, thus, early diagnosis and treatment are
critical to the prevention of future disability. There is a growing body of research
identifying that effective treatment for PTSD and cognitive-behavioral approaches
along with exposure therapy are most likely to be beneficial.

A Summary of Disaster Mental health Response Principles (Center for Disease

Control and Prevention, 2005).

Guiding Principles (It is helpful to keep these points in mind when preparing for or
responding to a disaster.)

• No one who experiences a disaster is untouched by it.

• Most people pull together and function during and after a disaster, but their
effectiveness is diminished.
• Mental health concerns exist in most aspects of preparedness, response, and
recovery.
• Disaster stress and grief reactions are “normal responses to an abnormal situation.”
• Survivors respond to active, genuine interest and concern.
• Disaster mental health assistance is often more practical than psychological in nature
(offering a phone, distributing coffee, listening, encouraging, reassuring, comforting).
• Disaster relief assistance may be confusing to disaster survivors. They may
experience frustration, anger, and feelings of helplessness related to Federal, State,
and non-profit agencies’ disaster assistance programs. They may reject disaster
assistance of all types.
PACE PLANNING
FIRE
SHELTER IN PLACE
• Sometimes the best way to stay safe in an emergency is to get inside
and stay put inside a building or vehicle. Where you should stay can
be different for different types of emergencies.

SHELTERING
• Finding protection from an environmental hazard by sealing oneself
in a safe and secure location instead of fleeing or evacuating. One
must stay indoors and rely on stored supplies or, if materials must be
imported from a contaminated environment, rely on filtration systems
that remove toxins, viruses, bacteria, and other potentially dangerous
materials until the hazard passes.
Get Inside, Stay Inside
• If local officials tell you to “stay put,” act quickly. Listen carefully to
local radio or television stations for instructions, because the exact
directions will depend on the emergency situation. In general you
should:
• Get inside. Bring your loved ones, your emergency supplies, and
when possible, your pets,
• Find a safe spot in this location. The exact spot will depend on the
type of emergency,
• Stay put in this location until officials say that it is safe to leave.
Stay in Touch
• Once you and your family are in place, let your emergency contact know what’s happening, and
listen carefully for new information.
• Person sending text to emergency point of contact.
• Once you’re inside and in a safe spot, let your emergency contact know where you are, if anyone
is missing, and how everyone is doing.
• Call or text your emergency contact. Let them know where you are, if any family members are
missing, and how you are doing.
• Use your phone only as necessary. Keep the phone handy in case you need to report a life
threatening emergency. Otherwise, do not use the phone, so that the lines will be available for
emergency responders.
• Keep listening to your radio, television, or phone for updates. Do not leave your shelter unless
authorities tell you it is safe to do so. If they tell you to evacuate the area, follow their
instructions.
Sheltering with pets
• Prepare a spot for your pets to poop and pee while inside the shelter.
You will need plenty of plastic bags, newspapers, containers, and
cleaning supplies to deal with the pet waste.
• Do not allow pets to go outside the shelter until the danger has
passed.
Sealing a Room
• In some types of emergencies, you will need to stop outside air from
coming in. If officials tell you to “seal the room,” you need to:
• Turn off things that move air, like fans and air conditioners,
• Get yourself and your loved ones inside the room,
• Bring your emergency supplies if they are clean and easy to get to
• Block air from entering the room, and
• Listen to officials for further instructions.
• Once officials say the emergency is over, turn on fans and other things
that circulate air. Everyone should go outside until the building’s air
has been exchanged with the now clean outdoor air.
Staying Put in Your Vehicle
• In some emergencies it is safer to pull over and stay in your car than to keep driving. If you are very close to home,
your workplace, or a public building, go there immediately and go inside. Follow the “shelter-in-place”
recommendations for that location. If you can’t get indoors quickly and safely:
• Pull over to the side of the road.
• Stop your vehicle in the safest place possible and turn off the engine.
• If it is warm outside, it is better to stop under a bridge or in a shady spot so you don’t get overheated.
• Stay where you are until officials say it is safe to get back on the road.
• Listen to the radio for updates and additional instructions.
• Modern car radios do not use much battery power, so listening to the radio for an hour or two should not cause
your car battery to die.
• Even after it is safe to get back on the road, keep listening to the radio and follow directions of law enforcement
officials.
PACE PLANNING
• These are layers of redundancy to ensure essential capabilities are
available at all times under any circumstances. The PACE technique
applies to the different methods of survival: primitive, bushcraft,
military, or blended.
• The PACE method is a valuable
method to help you think
through maintaining essential
capabilities while outdoors.
There is no right or wrong
solution to determining your
critical capabilities.
• the PACE method helps you to
think through the preparedness
process and to resource your
needs.
• You should apply PACE planning
to all vital areas of family
preparedness, such as
evacuation routes and means,
food supply, communications,
shelter, fire, water, food, helpful
friends, link up points and so on.
Disaster Triage
BASIC PRINCIPLES OF DISASTER TRIAGE
• “Triage is a process which places the right patient in the right place at
the right time to receive the right level of care” (Rice & Abel, 1992).
• The word “triage” is derived from the French word trier, which means,
“to sort out or choose.”
• The Baron Dominique Jean Larrey, Napoleon’s chief surgeon, is
credited with organizing the first triage system (Robertson-Steele,
2006). The U.S. military first used triage to describe a sorting station
where injured soldiers were distributed from the battlefield to distant
support hospitals.
• Triage is the process of prioritizing which patients are to be treated first
and is the cornerstone of good disaster management in terms of
judicious use of medical resources (Auf der Heide, 2000).
• AIMS: To do the greatest good for the greatest number of afflicted.
Abilities that are essential to be an effective triage officer
during a disaster ,Burkle (1984)
• ■Clinically experienced
• ■ Good judgment and leadership
• ■ Calm and cool under stress
• ■ Decisive
• ■ Knowledgeable of available resources
• ■ Sense of humor
• ■ Creative problem solver
• ■ Available
• ■ Experienced and knowledgeable regarding anticipated
casualties
Terminology
• Daily triage is performed by nurses on a routine basis in the ED,
often utilizing a standardized approach, augmented by clinical
judgment
• Incident triage occurs when the ED is stressed by a large
number of patients due to an acute incident or an ongoing
medical crisis such as pandemic influenza, but is still able to
provide care to all patients utilizing existing agency
re_x0002_sources
• Disaster triage is a general term employed when local EMS and
hospital emergency services are overwhelmed to the point that
immediate care cannot be provided to everyone who needs it
because sufficient resources are not immediately available.
• Minimal or minor (designated with the color green): These are
patients who are physiologically well compensated and likely to
remain so for an extended period of time.
• Delayed (designated with the color yellow): These are patients with
compensated physiology but a significant potential for deterioration or
morbidity if there are long delays before definitive care can be
provided.
• Immediate (designated with the color red): These are pa_x0002_tients
with uncompensated physiology and injuries that are life-threatening
but probably amenable to rapid interventions that do not require
consumption of an inordinate amount of resources.
• Deceased (designated with the color black): These patients are those
with no detectable vital signs, typically identified as victims not
breathing on their own.
• Expectant (designated with the color gray): These patients are those
who are still alive but due to their injuries and/or medical condition are
Population-based triage:
• Everyone in the population requires some intervention,
ranging from timely and accurate medical
infor_x0002_mation to vaccination and/or prophylaxis.
• The main goal of population-based triage is to prevent
secondary illness or injury such as disease transmission
from infectious individuals or foodborne illness from
contaminated or poorly refrigerated supplies.
• Infectious disease containment strategies, such as social
distancing, sheltering-in-place, isolation, and quarantine,
are the first line of management under state public health
law.
SEIRV classifications
■ Susceptible individuals—those individuals who are
unex_x0002_posed but susceptible.
■ Exposed individuals—susceptible individuals who have been in
contact with the disease and may be infected and
incubating but still noncontagious.
■ Infectious individuals—persons who are symptomatic and contagious.
■ Removed individuals—persons who no longer can pass the disease to
others because they have survived and developed immunity or died from
the illness.
■ Vaccinated or on prophylactic antibiotics—persons in this group are a
critical resource for the essential workforce.
Phases of triage :from field to hospital
• Primary- initial gross sorting of patients in the field.
– The goal of primary triage is usually to sort patients into five triage categories: Immediate, Delayed, Minimal,
Expectant, and Dead.
– The primary triage phase is similar to the trauma primary survey, in which physiology is the focus rather than
identification of specific injuries

• A second patient assessment (“secondary triage”) may be performed on-scene if

transport is delayed for any reason or at the hospital itself. In secondary triage,
additional informa_x0002_tion about each patient is obtained through a more
thorough physical assessment and history (when available). This is similar to the
traditional trauma secondary survey, in which physiology is reassessed and obvious
injuries are identified.

• “Tertiary triage” may then become necessary if the hospitals’ resources become
overwhelmed. In this step, hospital personnel determine if the facility can provide
appropriate care or if the patient will require stabilization and transfer to a facility
capable of a higher level of care. I
TRIAGE TOOL

• SALT ( Sort Assess Live saving Interventions)

• START
• JumpSTART
SALT

• It is nonproprietary and meets the model uniform core

criteria for mass casualty triage. SALT stands for Sort-
Assess-Lifesaving interventions-Treatment/transport,
which describes the steps followed when performing
SALT triage (Lerner et al., 2008)
• It uses an all-hazards approach that is intended to be
used for any age patient in any type of event
• The first step of SALT triage is global sorting. This step prioritizes patients for
individual assessment using two voice commands.
• The second step in SALT Triage is the individual assess_x0002_ment of
each casualty. The individual assessment should begin with considering if the
victim needs lifesaving interventions.
– These interventions include: (a) controlling major hemorrhage; (b) opening
the airway with a basic airway maneuver (Two rescue breaths may also
be delivered if a child is apneic after upper airway positioning; these
breaths are given in an effort to help open the mid to lower airways.); (c)
performing needle decompression for a possible tension pneumothorax;
and (d) providing autoinjector antidotes.
Once any lifesaving interventions are performed, the responders should evaluate the patient and
prioritize him or her for treatment and/or transport.
■ Dead: those who are not breathing even after lifesaving interventions have been attempted.
■ Immediate: those with difficulty breathing, uncontrolled hemorrhage, absence of peripheral
pulses, and/or inability to follow commands; who are likely to survive given the available resources
■ Expectant: those with difficulty breathing, uncontrolled hemorrhage, absence of peripheral pulses,
and/or inability to follow commands; who are unlikely to survive given the available resources.
■ Delayed: those who are alert and follow commands, have palpable peripheral pulses, no signs of
respiratory distress,
and all bleeding is controlled, with injuries or an illness that in the opinion of the rescuer is more than
minor.
■ Minimal: those who are alert and follow commands, have palpable peripheral pulses, no signs of
respiratory distress, and all bleeding is controlled, with injuries/condition that in the opinion of the
rescuer are minor
START

• The START triage tool is a commonly used adult MCI

primary triage tool developed by the Newport Beach Fire
and Marine Department and Hoag Hospital in California,
first published in 1983 and revised in 1994 (Benson,
Koenig, & Schultz, 1996).
• It was devised for use only for adults, with an arbitrary
lower application limit of a patient weight of 100 pounds.
Basic parameters assessed with START

• (a) the ability to walk,

• (b) the presence or absence of spontaneous respirations,
• (c) the respiratory rate,
• (d) an assessment of perfusion, and
• (e) the ability to obey commands.
JumpSTART

• The JumpSTART Pediatric MCI Triage Tool was the first

objective tool developed specifically for the primary triage of
children in the multicasualty/disaster setting. JumpSTART was
developed in 1995 and modified in 2001 by Dr. Lou Romig, a
pediatric emergency medicine physician with a background in
both EMS and pediatric disaster preparedness and response.

• Dr. Romig recognized that there were several decision

thresholds for START that were not appropriate for pediatric
physiology. JumpSTART addresses the unique physiology of
children while paralleling the structure and procedures of
START (Romig, 2002, 2007, 2011).
 JumpSTART differs in several key ways from START:

• 1. JumpSTART should be used for “all victims who appear to be children” and START for “all
victims who appear to be young adults or older.” This means that START should be used for
“tweens and teens” who have adult respiratory mechanics but may weigh less than START’s
stated lower limit of 100 pounds.
• 2.START’s criterion for being tagged Minor is the ability to walk, but this may be inaccurate when
triaging very young children and those with developmental or motor disabilities that prevent
unassisted ambulation.
• 3. Any child who is carried to the designated location when the walk command is given should be
individually assessed first when sufficient personnel become available to attend to the patients in
that area.
• 4. Because children primarily sustain respiratory failure/arrest before their hearts stop, there may
be a short time period where a child may be apneic but still have detectable circulation.
• 5. Because a slow respiratory rate has more dire implications than tachypnea in a child,
JumpSTART adds a low respiratory rate as a critical threshold.
• 6. Young children may be unable or unwilling to obey simple commands because they are not
developmentally or behaviorally capable or are just scared. Therefore, the AVPU (alert, voice,
pain, unresponsive) scale is used as an indicator of mental status rather than simply the ability to
obey commands.
Triage Tags
Job of Triage Officer
• The primary responsibility of the triage officer is to ensure
that every victim has been found and triaged.
• Triage officers (meaning the person[s] in charge of triage,
not implying a rank) and those responders assigned to
perform triage do not provide immediate treatment other
than to provide lifesaving interventions such as opening
airways and trying to control active bleeding.
• In traditional MCI triage, the triage officer carries only
supplies for performing lifesaving interventions and triage
tags.