Chapter
Mental Health
28 Barbara Lopes Cardozo and Richard Francis Mollica
Introduction
Worldwide, there is a considerable burden of morbid-
ity, mortality and disability associated with mental ill-
nesses. The Global Burden of Disease Study indicated
depression as the fourth leading disease burden in 1990
and is predicted to move to second place by 2020
(Murray and Lopez 1996). Further, five of the ten
leading causes of disability globally were due to psy-
chiatric conditions. Mental health is a core public
health issue in emergency settings including during
humanitarian emergencies. In these settings, the need
for a mental health approach is critical. Although the
Global Burden of Disease report did not concentrate
on emergencies, the burden of mental illness is likely
much greater among traumatized and displaced popu-
lations. Despite the challenges of assessing the preva-
lence of mental illness in emergency settings, studies
reveal the serious impact of conflict and natural disas-
ters on mental health (Mollica, et al. 2004). The need to
address mental health issues in humanitarian emergen-
cies has become evident in recent years.
Not only manmade or natural disasters have
major mental health consequences – the psychological
consequences and effects on mental health on indivi-
duals and populations in the event of epidemics, such
as severe acute respiratory syndrome (SARS) (Tam
2004), H1N1 (Goodwin 2009), HIV/AIDS, Ebola (De
Roo 1998), and other infectious diseases, are
enormous.
Suicide, which is closely related to mental illness, is
another concern in humanitarian emergencies. It is the
main contributor to mortality associated with mental
illness. More than 90 percent of people who die from
suicide have a mental disorder. Suicide is among the top
20 leading causes of death globally for all ages.
Every year nearly one million people die from suicide
(WHO 2011b). Mental illness, primarily depression,
alcohol-use disorders and abuse, violence, loss, cultural
and religious beliefs (e.g., belief that suicide is a noble
resolution of a personal dilemma), local epidemics of
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suicide, isolation, a feeling of being cut off from other
people, and barriers to accessing mental health treat-
ment represent major risk factors for suicide (CDC
2013). Most importantly, suicide risk may be higher in
countries affected by war and conflict and especially
among refugees.
Unfortunately, few studies have been conducted to
detect the risk of suicide among refugees resettled to
third countries. Additionally, there is no research
assessing suicide risk in refugee camps. One study
however showed that Bhutanese refugees who were
resettled to the US were at a higher risk for suicide
compared with the general US population or the esti-
mated annual global suicide rate for all persons
(Cochran 2013). Another study found suicidal idea-
tion was associated with posttraumatic stress disorder
(PTSD) in postwar Kosovo (Wenzel et al. 2009).
Focus on the interconnectedness of physical and
mental health cannot be ignored in humanitarian emer-
gencies. The Surgeon General’s landmark report on
mental health in 1999 raised awareness about the inter-
connectedness of the mind and the body with physical
and mental health (Office of the Surgeon General 1999).
Physical health cannot be adequately addressed without
also addressing mental health. The Surgeon General’s
Report highlighted the potential impact of mental ill-
ness on a person’s ability to understand and practice
health promotion and disease prevention.
Three decades ago little was known about the
importance of identifying and caring for the mental
health impact of manmade and natural disasters. This
is no longer the case. Not only have the links between
mental health and physical health been firmly estab-
lished in humanitarian emergencies, but also effective
culturally valid clinical and preventative strategies
efforts have emerged (Mollica 2011).
Burden of Disease
Until 1988, no mental health surveys had been con-
ducted among refugee or war-affected populations.

In 1988, the first on-site mental health survey was
conducted among the Cambodian refugees staying
in Site 2, a Thai refugee camp on the Cambodian
border. This survey showed a 37 percent prevalence
of PSTD and 68 percent depression (Mollica 1993).
A cross-sectional survey conducted in 1996 of
Bosnian refugee adults living in a camp established
by the Croatian government near the city of Varazdin
showed that 39 percent and 26 percent of reported
symptoms met Diagnostic Statistical Manual (DSM)
criteria for depression and PTSD, respectively
(Mollica et al. 1999). A mental health survey in
Kosovo, conducted shortly after the end of the war
in 1999, showed that 17 percent of the people had
symptoms of PTSD (Lopes Cardozo et al. 2000).
In a follow-up survey in 2000, this number increased
to 25 percent (Lopes Cardozo et al. 2003). A 2002
nationwide mental health survey in Afghanistan
revealed that the prevalence within the population
for symptoms of depression was 68 percent; 72 percent
of the population had symptoms of anxiety.
The prevalence of the Afghan people with symptoms
of PTSD was 41 percent (Lopes Cardozo et al. 2004).
In comparison, in a given year, major depressive
disorder affects approximately 6.7 percent of the
U.S. population age 18 and older, and about 3.5 per-
cent of people in this age group have PTSD (NIMH
2011, Kessler et al. 2005). An overview of mental
health surveys in populations affected by war and
conflict that conducted from 1993 until the present
is shown in Table 28.1. Compared with prevalences
for depression and PTSD in the US population, people
in war-torn countries have much higher levels of
symptoms of PTSD and depression. The prevalence
of serious mental disorders such as PTSD among
refugees resettled to Western countries has been esti-
mated to be ten times higher than the age-matched
general population (Fazel et al. 2005).
Risk and Mitigating Factors
Individual
Mental health surveys have identified a number of risk
factors associated with poorer mental health out-
comes. Exposure to traumatic experiences is a major
risk factor linked to the development of not only
PTSD, but also depression and poorer social function-
ing (Lopes Cardozo et al. 2000). In several surveys,
women were shown to be at higher risk than men for
developing mental health problems. Specific risk
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Chapter 28: Mental Health
patterns were identified for different countries,
which included a history of psychiatric illness or phy-
sical illness, torture, and separation or death of family
members (de Jong et al. 2001). In a study among
Guatemalan refugees in Chiapas, Mexico, respon-
dents who had witnessed a massacre were at risk for
elevated anxiety symptom scores (Sabin et al. 2003).
Community
At the community level, poor quality of camp condi-
tions was associated with higher risk of developing
PTSD in a number of countries (de Jong et al. 2001).
In a refugee camp in Thailand, economic activity was
significantly associated with decreased likelihood of
depression (Mollica et al. 2002). Another study in
Thailand among Karenni refugees in the Thai-
Burmese border camps identified several psychosocial
risk factors, some of which could be modified by
changes in refugee policy in the Karenni camps
(Lopes Cardozo et al. 2004). In particular, the policy
to forbid movement, employment, and cultivation of
land outside the camps appeared to negatively affect
the social functioning and mental health of the
Karenni refugees. The psychosocial well-being of
refugees would probably improve by amending refu-
gee policy to allow for income generation and move-
ment outside camps.
Identifying Mental Health and
Psychosocial (MHPS) Needs
In a humanitarian emergency, it is important to iden-
tify the specific mental health and psychosocial needs
of the affected community. As early as possible,
a rapid Mental Health and Psychosocial (MAPS)
assessment should be conducted. A guideline on
assessing MHPS needs and resources in humanitarian
emergencies can be found at:
• www.who.int/mental_health/resources/toolkit_m
h_emergencies/en/
As soon as feasible during a humanitarian emergency
a comprehensive MHPS survey should be conducted.
Survey methodology is discussed in detail in
Chapter 8. The main difference between conducting
MHPS surveys compared with surveys in other public
health fields lies for the most part in the types of
questions and instruments being used. In most
cases, to perform a MHPS survey it will be necessary
to adapt standard instruments according to the con-
text and culture. Qualitative methods using key
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 Section 3: Illness and Injury

Table 28.1 Mental health surveys in populations affected by war and conflict that conducted from 1993 until the present

Study Group Prevalence Prevalence of Nonspecific Screening Reference

of PTSD (%) Depression (%) mental health method
morbidity (%)
Cambodian 37.2 67.9 HTQ Mollica et al.
refugees in HSCL-25 (1993)
Thailand
Bosnian refugees in 26 39 HTQ Mollica et al.
Croatia HSCL-25 (1999)
Kosovar Albanians 17.1 N/A 43 (11 mean HTQ Lopes Cardozo
in Kosovo score) GHQ-28 et al. (2000)
Rwandan Refugees N/A N/A 50 (14 mean GHQ-28 De Jong et al.
in Tanzania score) (2000)
Afghan population 42.1 67.7 Lopes Cardozo
et al. (2004)
Karenni (Burmese) 4.6 41.8 GHQ-28 Lopes Cardozo
refugees in HSCL-25 et al. (2004)
Thailand
HTQ
Sri Lanka internally 7.0 30.7 HSCL-25 Husain et al.,
displaced persons HTQ 2011
in Jaffna
Cambodia (Siem 20.6 49.5 HSCL-25 Mollica et al.
Reap) HTQ 2013
Algeria Lifetime: 37.4 LESHQ De Jong JT et al.
CIDI (2001)
Ethiopia Lifetime: 15.8 LESHQ De Jong JT et al.
CIDI (2001)
Gaza Lifetime: 17.8 LESHQ De Jong JT et al.
CIDI (2001)
U.S. Population 12-month: 3.5 12-month: 6.7 CIDI Kessler, Chiu,
et al. (2005)
Lifetime: 6.8 Lifetime: 16.6 (modified) Kessler,
Berglund, et al.
(2005)

informants and, if necessary, focus group discussions
should be used to identify specific traumatic events
and stressors, coping mechanisms and support sys-
tems, the way symptoms of mental illness are
expressed in the culture, terminology, and function-
ing. According to the findings of this qualitative
assessment, the questions of the instruments for
a quantitative MPHS survey can be adapted or
formulated.
A key to valid cross-cultural assessment lies in
establishing equivalence with regard to language,
concepts, and scales within and between cultures
and ethnic groups. Because of a general lack of cross-
culturally validated mental health instruments, it is
difficult to compare populations in different countries
and different cultural contexts. The best possible solu-
tion at this time for measuring the mental health
status of populations in humanitarian emergencies is
to use instruments that have at least been validated
and field-tested in a number of countries. In an emer-
gency setting, the specific instrument should be cul-
turally validated for the specific country and context

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100
Percentage Population
Treatment
0
Cut-off Point
Severity
where they will be used. Resources, however, are often
not available to do so.
Instruments that have been used in many MHPS
surveys in humanitarian emergencies are the
Hopkins Symptom Checklist (HSCL) measuring
symptoms of anxiety and depression, and the
Harvard Trauma Questionnaire (HTQ) measuring
trauma events and PTSD symptoms as defined in
the DSM-IV. Another instrument developed by the
World Health Organization (WHO) is the Self-
Reporting Questionnaire (SRQ-20) that measures
general psychological distress. SRQ-20 has good
validity and reliability for adults (≥15 years) and
can be used both as a self- or interviewer-
administrated questionnaire. It consists of 20 closed
questions covering expression of distress, the total
score corresponding to the sum of positive
responses. It has been validated in several countries
including Rwanda, India, Vietnam, and Brazil.
PTSD, depression, anxiety, and other mental
health disorders common in humanitarian emergen-
cies need to be identified, but this could be a challenge
since they can manifest in a variety of ways in different
populations and cultures. Culture influences the clin-
ical presentation and distribution of mental illnesses.
However, the more severe the psychopathology, the
more likely a diagnosis is applicable across cultures –
for example, schizophrenia. The Harvard Program in
Refugee Trauma (HPRT) has developed a screening
manual that addresses all of the major issues in the
development and use of culturally valid screening
instruments to identify those traumatized and in
need of care (Mollica 2004). This includes the role of
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Chapter 28: Mental Health
Figure 28.1 Establishing a cut-off point for mental
health screening and treatment
preliminary needs assessments and the establishment
of resource-based cut-off points based upon the psy-
chometric properties of known instruments such as
the HSCL and HTQ. The method of establishing
a cut-off point for mental health screening and treat-
ment is shown in Figure 28.1.
In humanitarian emergencies, mental health pro-
blems may go undiagnosed and untreated because
symptoms of mental illness may be expressed differ-
ently than in Western societies. In many cultures, for
example, psychological problems are expressed as
physical symptoms (e.g., headache, bodily pains, sto-
mach aches, etc.).
The Diagnostic Statistical Manual-5 (DSM-5)
has introduced a new terminology called “cultural
concept of distress” (CCD). The concept refers to
different ways groups of people in a particular cul-
ture may experience, understand, and express dis-
tress (DSM-5). It has been suggested that inclusion
of CCD in epidemiological studies can improve
detection of psychological distress that may other-
wise be missed using conventional instruments
(Kohrt et al. 2013).
Overall, those assigned to determining the mental
health impact of humanitarian emergencies must
decide how to identify and screen for traumatized
persons at high risk for mental health problems, psy-
chiatric morbidity, and health-related physical illness.
This is not an easy task, especially in resource-poor
environments, in light of the reality that almost all
affected persons will exhibit some forms of emotional
distress. The aims and goals of mental health screen-
ing must be clearly defined and acknowledged at the
411
 Section 3: Illness and Injury
outset of a disaster. Resources must be linked to the
capacity to provide culturally effective care.
Best Practices
Emergency Risk Communication
During a humanitarian emergency, especially from
sudden onset disasters such as an earthquake, other
natural disasters, technological disasters, or outbreak
of a disease, risk and crisis communication is very
important. The stress of uncertainty and anxiety
about the events may make some people physically ill.
They may experience stress-related symptoms such as
headaches, upset stomach, and pain (Reynolds and
Seeger 2012). It may be a problem when the worried-
well burden a healthcare system that may already be
overloaded during a humanitarian emergency. Early
and good communication with the public may help
avoid unnecessary use of resources. As an example,
after a volcano eruption in Colombia, when an entire
village was buried under the mud, many people were
demanding vaccinations against tetanus, even those
who were far removed from the disaster site and were
not injured at all (personal communication, Lopes
Cardozo).
Six principles of good crisis risk communica-
tion to persons affected by a humanitarian cata-
strophe are (Reynolds and Seeger 2012):
• Be first
• Be right
• Be credible
• Express empathy early
• Promote action
• Show respect
It is important for the communicator to understand
that in crisis, people often manifest psychological
reactions that may become psychological barriers if
they are not handled well. In an emergency, these
include individuals experiencing fear, anxiety, confu-
sion, and even dread. Contrary to popular myths, it is
actually quite uncommon for people to panic
(Reynolds and Seeger 2012). Most people are able to
act rationally even when faced with extreme stress.
It is not the role of mental health professionals and
spokespersons to make these feelings go away; rather
it is helpful to acknowledge these feelings in an empa-
thetic way. If feelings of fear go unchecked, feelings of
hopelessness and helplessness and eventually with-
drawal, if the person becomes overwhelmed by fear,
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may set in (Reynolds and Seeger 2012). To avoid this,
it is helpful to set the community or the individual on
a course of action, including encouraging people to
take action and asking them to do things that are
constructive and helpful in the given crisis. Anxiety
is reduced by action and gives a sense of control
(Reynolds and Seeger 2012). The WHO established
in an important historic declaration the context and
overall aim of clear crisis communication (Petevi
2000).
Two additional principles of clear communication
are (Reynolds and Seeger 2012):
• Do no harm
• Establish a dialogue
Guidelines
For many years, mental health interventions were
not routinely included in humanitarian emergency
response. Lack of knowledge about the burden of
mental illness and uncertainty about the right
approach for mental health and psychosocial pro-
grams in humanitarian emergencies made it diffi-
cult for humanitarian agencies to implement
mental healthcare. The Interagency Standing
Committee (IASC) Guidelines on Mental Health
and Psychosocial Support (MHPS) in Emergency
Settings were created in 2007 to address the latter.
In the IASC Guidelines, the composite term mental
health and psychosocial support (MHPSS) was
used to describe “any type of local or outside sup-
port that aims to protect or promote psychosocial
well-being and/or prevent or treat mental
disorder.”
These guidelines were based on a consensus
approach among many agencies, that were imple-
menting or considering implementing MHPSS pro-
grams. Although the guidelines were based on
a best practices approach and not backed up by
outcome evaluations and other scientific evidence
(Lopes Cardozo 2008), these guidelines proved to be
a major step forward in the MHPS field.
Furthermore, mental health has now also been
included in the SPHERE Standards (2011) as an
essential health service.
The IASC Guidelines describe the concept of an
intervention pyramid that outlines the type of services
from basic to specialized, at each stage of the pyramid,
from larger to fewer numbers of people needing dif-
ferent levels of care. This is shown in Figure 28.2.
 Chapter 28: Mental Health

Intervention pyramid

Examples:

Mental health care by mental health

specialists (psychiatric nurse,
psychologist, phychiatrist, etc). Specialised
services

Basic mental health care by PHC doctors. Focused

Basic emotional and practical support by (person-to person)
community workers non-specialised
supports

Activating social networks Strengthening

communal traditional supports community and
Supportive child-friendly spaces family supports

Advocacy for basic services that are Social considerations

safe, socially appropriate and protect in basic services
dignity and security

Figure 28.2 Intervention pyramid outlining the type of services from basic to specialized
Source: Interagency Steering Committee Reference Group on Mental Health and Psychosocial Support, 2010

Generally, intervention at the base of the pyramid
tends to be more focused on the social aspects of
psychosocial interventions. Those at the top level of
the pyramid are focused towards people who suffer
from serious mental illness and/or have substantial
impairment in daily functioning because of emotional
problems. The assistance directed at this segment of
the population should include psychological or psy-
chiatric support for people with severe mental disor-
ders. Such problems require either referral to
specialized services, if they exist, or initiation of longer
term training and supervision of primary healthcare
providers in psychiatric skills. While these specialized
services are needed for only a small percentage of the
population, in most large emergencies this group
amounts to thousands of individuals (IASC 2007).
During the emergency phase, the IASC Guidelines
recommend establishing services through the primary
healthcare system to address urgent psychiatric pro-
blems and ensuring availability of essential psycho-
tropic medications at health facilities. In the post
emergency or reconsolidation phase of an emergency,
the IASC Guidelines recommend training and super-
vision of primary healthcare workers in basic mental
health knowledge and skills. Education of humanitar-
ian aid workers and community leaders in basic psy-
chological skills is also recommended. Medication for
psychiatric patients should be made readily available
in the reconsolidation phase. Finally, collaboration
with traditional healers is encouraged (IASC 2007).
Treatment Approaches
Integrating Mental Healthcare
According to WHO, around 75 percent of people with
psychiatric, neurological, and substance use disorders
in developing countries do not have access to proper
care and treatment. WHO also reports that the
resources available for mental health are insufficient,
inequitably distributed, and are inefficiently used.
The WHO Mental Health Gap Action Programme

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 Section 3: Illness and Injury
(mhGAP) aims to scale up mental health services for
psychiatric, neurological, and substance use disorders
especially for low- and middle-income countries
(WHO 2012b). The WHO focus is on utilizing pri-
mary healthcare providers to provide basic mental
healthcare. This emphasis on primary healthcare
applies to humanitarian emergencies as well.
Community Approach
Certain types of mental health interventions fall under
the spectrum of the term psychosocial. In most post-
emergency situations, poverty is a big problem, which
may have a substantial effect on the mental health and
well-being of the affected population. Income generat-
ing projects can help overcome some of the negative
effects of poverty and lack of income. It is important for
children that the situation returns to normal as much as
possible by facilitating recreational activities and help-
ing children to go back to school as soon as possible.
Depending on the culture and environment, the crea-
tion of community-based self-help support groups is
useful.
Counseling
There is a gap in scientific knowledge of the effective-
ness of treatment approaches in humanitarian emer-
gencies, postconflict environments, and in low-
resource countries. During and after humanitarian
emergencies, a variety of treatment approaches have
been used by international humanitarian organiza-
tions, mental health institutions, and mental health
professionals. The more commonly implemented
mental health practices are counseling, nonpharma-
cological management of mental disorders by general
healthcare providers, and training of nonspecialized
personnel such as community workers and teachers
(Tol et al. 2011). A systematic review of the literature
focusing on acute humanitarian emergencies revealed
a small number of treatment evaluation studies (N =
16) of which only about a third used randomized
controlled trial methodology. Because of the hetero-
geneity of these studies, it is not possible to provide
strong recommendations for MHPS intervention in
humanitarian emergencies (de Jong et al. 2014).
At this time, the following recommendations are
made until further research is conducted:
• Counseling is a commonly used method of
treatment but can mean different things to
different people. Sometimes, it is understood as
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a form of psychotherapy, other times as a basic
supportive intervention. A review of the
scientific literature revealed that culturally
adapted counseling interventions were more
likely to result in an effective intervention than
generic counseling approaches. Trained,
clinically supervised, lay counselors
implemented most of the reviewed
interventions. Nonculturally adapted counseling
approaches did not affect anxiety and depression
symptoms; those that were culturally adapted
did (de Jong et al. 2014).
• Psychosocial Debriefing was originally thought as
the pinnacle of care for highly traumatized
persons and communities and widely used, for
example, after the 9/11 Twin Tower catastrophe,
but has dramatically fallen out of favor (Van
Emmerick et al. 2002). Psychosocial Debriefing as
described by the American Psychological
Association is “a formal version of providing
emotional and psychological support immediately
following a traumatic event; the goal of
psychological debriefing is to prevent the
development of post-traumatic stress disorder and
other negative effects” (American Psychological
Association, Division 12, 2008). The timing of
debriefing and the professional level of support
have varied considerably. The cultural
appropriateness of asking persons to state openly,
and often to a stranger from an outside
community, the precise details of their traumatic
experiences has been challenged as highly
questionable and may even increase the
individual’s emotional distress, including the
symptoms of PTSD (Rose et al. 2001).
• Psychological First Aid (PFA) is listed as the best
practice in humanitarian emergency
environments and increasingly practiced by
humanitarian workers. The 2011 SPHERE
Standards mentions Psychological First Aid as one
of the major interventions in emergencies.
The SPHERE Handbook describes Psychological
First Aid as a “humane, supportive response to
a fellow human being who is suffering and who
may need support. It entails basic, non-intrusive
pragmatic care with a focus on listening but not
forcing talk, assessing needs and concerns,
ensuring that basic needs are met, encouraging
social support from significant others and
protecting from further harm.”

• PFA has become increasingly popular and is being
applied extensively in humanitarian emergencies,
especially since debriefing has fallen out of favor.
Yet there is an absence of quantitative data
containing evidence to support PFA following
traumatic events. However, it is apparent
scientifically that certain risk factors, such as
traumatic dissociation and lack of support, are
associated with higher rates of emotional distress,
and quite possibly lead to PTSD and depression
(Bisson and Lewis 2009).
• Clearly, crisis intervention needs to address these
factors. There is also a widespread belief in the
humanitarian aid community that a sense of
safety, hope, connectedness, and caring by the
international community and humanitarian aid
workers be promoted actively. The cultural and
interpersonal sensitivity of the affected
communities and families, however, must guide
PFA with a major enforcement and buy-in by the
local community and its leadership (National
Child Traumatic Stress Network and National
Center for PTSD 2006).
Treatment of DSM Mental Health
Disorders
The Diagnostic and Statistical Manual of Mental
Disorders (DSM), published by the American
Psychiatric Association, contains common language
and standard criteria for the classification of mental
disorders.
The most common DSM psychiatric disorders
occurring during humanitarian emergencies are depres-
sion, anxiety, complex grief, and posttraumatic stress
disorder (PTSD). People with preexisting mental disor-
ders (e.g., bipolar illness, schizophrenia, and substance
abuse) may experience an exacerbation in their symp-
toms due to increased stress, lack of medication, and the
collapse of the mental health treatment system. The
management and the treatment of the latter chronic
mental illnesses are beyond the scope of this chapter.
Depression and Anxiety
Depression in the aftermath of humanitarian emergen-
cies is common and the majority of patients respond
well to treatment. Treatments that have been shown to
be effective are antidepressant medications and psy-
chotherapy or a combination of both. Older types of
antidepressants such as tricyclic antidepressants
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Chapter 28: Mental Health
(TCAs) (e.g., amitriptyline) are effective but usually
have more side effects than newer antidepressants
such as selective serotonin reuptake inhibitors (SSRIs)
(e.g., fluoxetine, paroxetine) or the atypical antidepres-
sants (e.g., bupropion). Benzodiazepines are not recom-
mended for the treatment of depression. Nevertheless,
they are often overprescribed in the context of huma-
nitarian emergencies due to lack of knowledge and
training of healthcare providers and sometimes lack of
availability of other psychotropic medications.
Additionally, a meta-analysis showed that different psy-
chotherapeutic interventions are effective with more
robust evidence for cognitive-behavioral therapy, inter-
personal therapy, and problem-solving therapy (Barth
et al. 2013). However, few of these studies have been in
emergency or low-resource settings. One study in rural
Uganda showed that group interpersonal psychother-
apy was highly effective for the treatment of major
depression and dysfunction (Bolton et al. 2003). It is
important to keep in mind that it may take several
weeks before antidepressant medications take effect
and that it is necessary to continue treatment for at
least six months to a year and much longer in some
patients. Continued treatment and follow-up may be
a problem in emergency settings.
Anxiety disorders are also common during huma-
nitarian emergencies. In Western countries with a lot of
resources, treatments that have been shown to be effec-
tive are cognitive behavioral therapy (CBT) and medi-
cation in particular benzodiazepines (e.g., diazepam,
clonazepam, alprazolam) and for some patients’ SSRI
antidepressants. However, CBT is often not a form of
psychotherapy that is being practiced or taught to psy-
chotherapists in humanitarian emergency settings.
Acute anxiety after exposure to extreme stressors such
as traumatic events in an emergency is initially best
managed following the principles of PFA. If this
approach is not sufficient, primary care providers
could consider prescribing a benzodiazepine for
a short period of time (Jones 2011). For a diagnosis of
major depression, related disorders and generalized
anxiety need to be addressed; the basic symptom criteria
in the new DSM-5 have not significantly changed (APA
2013).
Posttraumatic Stress Disorder (PTSD) and
Acute Stress Disorder (ASD)
PTSD may occur if people are exposed to traumatic or
stressful events, serious injury, or sexual violence.
415
 Section 3: Illness and Injury

Effective treatment includes psychotherapy, especially
CBT. Exposure therapy is a specific form of CBT that
is considered the gold standard, first-line intervention
for PTSD in Veterans (Eftekhari et al. 2013). Eye
movement desensitization and reprocessing (EMDR)
is another type of cognitive behavioral therapy for
PTSD. The goal of all forms of CBT is ultimately to
change how patients react to trauma memories. Other
types of psychotherapy may also be helpful, such as
group therapy, or psychodynamic psychotherapy, but
the evidence of their effectiveness from clinical trials
and more rigorous studies is limited. SSRIs have also
been shown to be effective in many cases. Venlafaxine,
a serotonin-norepinephrine reuptake inhibitor
(SNRI), has also shown efficacy in the treatment of
PTSD (Jeffreys 2014).
The evidence for efficacy of these treatments for
PTSD during humanitarian emergencies and in its
aftermath is scarce. However, a literature review
focusing on CBT versus other PTSD psychotherapies
as treatment for women victims of war-related
violence revealed that various forms of CBT, includ-
ing cognitive processing therapy (CPT), culturally
adapted CPT, and narrative exposure therapy (NET)
contribute to the reduction of PTSD and depression
severity among these women (Dossa and Hatem
2012). In one study in the Democratic Republic of
Congo, a conflict-affected country, group psychother-
apy reduced PTSD symptoms and combined symp-
toms of depression and anxiety, and improved
functioning among women survivors of sexual vio-
lence (Bass et al. 2013). A few studies have also been
conducted among traumatized refugees who were
resettled in the US (Hinton 2004). CPT was effective
in decreasing PTSD symptoms among refugees who
had arrived from Afghanistan and Bosnia (Schulz
et al. 2006). However, there were some limitations to
this study, including lack of a control group.
There is some evidence that early intervention
with modified prolonged exposure therapy may pre-
vent the development of PTSD (Rothbaum et al.
2012). To date, however, no PTSD prevention studies
have been conducted in humanitarian emergencies.
Acute Stress Disorder (ASD) follows the same
symptoms as PTSD in the Diagnostic and Statistical
Manual of Mental Disorders (DSM-5). The difference
is that these symptoms occur in the first 30 days after
the trauma exposure. If the symptoms last for longer
than 30 days after the traumatic event, a diagnosis of
PTSD needs to be considered. The new trauma- and
stressor-related disorders category in the DSM 5 are
helpful for identifying and treating ASD and PTSD,
which are relatively common in humanitarian emer-
gencies. In the DSM-5, the diagnostic criteria have
been clarified and clearly link the occurrence of severe
traumatic or stressful events to the potential for the
development of ASD or PTSD if the symptoms persist
for more than 30 days. With a clearer diagnostic
category, clinicians will be more likely to choose the
correct treatment options.
Grief Reactions
Although most individuals are highly resilient to loss,
the unnatural death and loss of a loved one (spouse,
child, relative and friends) can lead to grief reactions
so severe that the bereaved becomes emotionally and
physically ill. All cultures have traditional and cultural
ceremonies and prescribed rituals associated with
grief and mourning. However, studies have demon-
strated that those who have had a child murdered,
suffer an unnatural death, or disappear in an emer-
gency are especially prone to complex grief reactions
that last longer than the cultural norm and are asso-
ciated with major depression. The DSM-IV allowed
for an “exclusion criteria” for depression associated
with grief so that a normal grief reaction would not be
misdiagnosed as a mental illness and associated with
possible stigma and use of medication. These exclu-
sion criteria have been removed in the DSM-5. Some
mental health professionals believe this may lead to
a medicalization of the grief reaction. Others say it
will lead to proper treatment of depression affecting
the bereaved. A new disorder in the DSM-5 called
Persistent Complex Bereavement Disorder has also
been proposed. This disorder describes grief reactions
with persistent and severe sadness, feelings of being
stuck on the loss, and invasive images and yearning
for the deceased person. These symptoms continuing
six months after the loss, need to be identified because
they can be severe and debilitating.
Grief reactions are so common in humanitarian
emergencies that it is necessary that the relief workers:
• Know the cultural expression and the traditional
support of grief
• Be able to identify those who are developing
a major grief-related physical and mental illness
and provide the proper care
While cultural and religious ceremonies, counseling,
and medication are often effective in caring for grief

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reactions, those with Persistent Complex
Bereavement Disorder are often refractory to these
treatments and will need specialized care (Shear
et al. 2011).
Mental Health and Chronic Disease
There is emerging evidence that refugees, persons
who have experienced natural disasters, and those
impacted by conflict and war have increased levels of
long term chronic disease attributable to their trau-
matic experiences and high levels of distress (Kinzie
et al. 2008, Spiegel et al. 2010, Roberts et al. 2012).
Specific traumatic events, such as torture, rape, dis-
appearance of a loved one, unnatural death of a family
member, and a history of child abuse, have the poten-
tial for negatively affecting a person’s health and
mental health status. While traumatic events can
lead to negative health outcomes directly, mental
health outcomes such as PTSD and depression can
be mediators of poor health and physical disease.
In a recent study in the Siem Reap province, it was
found that traumatic experiences 25 years earlier
impacted directly on functional and perceived health,
whereas with more recent traumatic experiences the
effect on mental health was directly related to PTSD
and depression (Mollica et al. 2014). Other authors
have further confirmed the relationship between
trauma, PTSD, and health outcomes (Sledjeski et al.
2008, Spitzer et al. 2009).
Key work in mainstream populations in this area
was initiated by Felitti and his colleagues. Their initial
research called The Adverse Childhood Experiences
Study (ACE study) (Anda et al. 2006) demonstrated
the impact of adverse childhood trauma on the phy-
sical health of fifteen thousand middle-class American
patients. This research is now being expanded to
include highly traumatized populations who have
experienced extreme violence, such as refugees, dis-
placed persons, and those affected by natural disasters
and humanitarian crises. Those working with highly
traumatized patients and communities in the emer-
gency phase must lay the groundwork for the preven-
tion of chronic illness such as diabetes, hypertension,
and heart disease that will have a major impact on
trauma survivors within the immediate or more long-
term future. Those who experience trauma are more
likely to die at a younger age, develop serious physical
illnesses, exhibit poor mental health, smoke more, use
drugs and alcohol more, exercise less, and have poor
eating habits (Anda et al. 2006). The direct and
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Chapter 28: Mental Health
indirect impact of trauma-related mental health dis-
orders such as PTSD and depression are now clearly
linked to increased mortality and morbidity. Research
has set the stage for the humanitarian community to
advance the prevention and care of chronic medical
disorders as a top priority that needs to be grounded
in early interventions during the emergency phase.
Mollica and his colleagues have built on this new
approach to elaborate a new H5 model (human rights,
humiliation, healing, health promotion, housing/
habitat) for the care of displaced populations and
other highly traumatized populations (Mollica et al.
2014).
Gender-based Violence and Women’s
Health
Over the past quarter century, a major revelation has
occurred within the international community con-
cerning populations affected by mass violence and
natural disaster: the major abuse of women in huma-
nitarian emergencies is sexual violence (Goldfeld et al.
1988). The physical and emotional abuse of women
can occur at epidemic proportions as witnessed in
Haiti after the recent earthquake (Gage and
Gutchinson 2006, Kolbe and Hutson 2006, Small
et al. 2008). Gender-based violence not only includes
rape but all forms of sexual abuse including traffick-
ing, enslavement, and domestic violence. It can affect
males and children as well as females. Gender-based
violence is highly associated with emotional distress
and psychiatric disorders (e.g., PTSD and depression),
drug and alcohol abuse, and similar behavior.
The experience of rape and sexual abuse is associated
with numerous medical problems including sexually
transmitted infections (STIs), HIV-AIDS, hepatitis C,
infertility, and a plethora of other women’s health
illnesses and symptoms.
Disasters create an environment for gender-based
violence due to the disruption of normal social life
and social structures, dislocation, death, loss of family
members, a chaotic living environment (poor hous-
ing, homelessness, lack of electricity), and a living
environment without lights (WHO 2002, Chew and
Ramdas 2005). All of the latter factors can facilitate
the physical and emotional abuse of the traumatized
populations, especially women, children, and the
elderly. A history of widespread domestic violence
and other forms of gender-based violence prior to
the disaster almost guarantees that it will occur and
417
 Section 3: Illness and Injury
even be enhanced during the new crisis and emer-
gency phase. Therefore, humanitarian aid during the
emergency phase of the humanitarian crisis must be
prepared to prevent and treat gender-based violence,
such as arresting and prosecuting those who prey on
survivors of a catastrophe when they are most vulner-
able and susceptible to victimization.
In addition to gender-based violence, the overall
vulnerability of women during and after disasters
can be extreme (Carballo et al. 2005). Women are at
a much greater risk of death, impact on pregnant
women can be extreme, contraception and family
planning breaks down, and poverty and care giving
roles are expanded. Social taboos, for example, for
women and girls in Bangladesh after the 1998 floods
revealed increased rashes and urinary tract infec-
tions because the women were not able to wash out
menstruation rags properly in private and had no
access to clean water for washing. Women’s health
issues can be associated with major mental health
problems and emotional distress. Yet, little is still
known about women’s health and mental health in
complex emergencies (American College of
Obstetricians 2010).
Humanitarian Aid Workers
Humanitarian work is demanding and stressful
(Lopes Cardozo et al. 2004, Ursano et al. 2006).
A typical deployment may include uncertainty over
deployment time, travel to an unfamiliar location with
uncertain living accommodations or work responsi-
bilities, exposure to victims or destruction, personal
risk of injury, worries over family or work back home,
political sensitivities and reentry into work or home
life (Eriksson et al. 2001, Lopes Cardozo et al. 2005).
Humanitarian work in complex emergencies is
increasingly dangerous. One review noted deaths
among international humanitarian workers working
for nongovernmental organizations have increased
since 1985 (Sheik et al. 2000, Lancet 2006). Much in
the same way that organizations attempt to reduce
individual risks associated with other occupational
work exposures such as work-space injuries or expo-
sure to biological or toxic agents, organizations that
employ aid workers or responders are identifying the
need for policy and programs that address the psy-
chological consequences of such work (Antares
Foundation, 2012). Several studies and surveys have
been conducted describing the consequences of stress
among international humanitarian aid workers
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(Lopes Cardozo et al. 2005, Holtz et al. 2002, Lopes
Cardozo et al. 2012) and local staff working in huma-
nitarian emergencies (Eriksson et al. 2012, Ager et al.
2012, Lopes Cardozo et al. 2013). In a survey among
expatriate humanitarian aid workers in Kosovo,
symptoms of depression were common, but symp-
toms of PTSD were not, although there was substan-
tial exposure to trauma. Aid workers who were on
their first assignment were at higher risk for develop-
ing mental problems than those who had been
deployed several times. However, aid workers who
had been on five or more assignments were again at
higher risk to develop mental problems.
Organizational support was an important mitigating
factor.
The IASC guidelines on mental health and psy-
chosocial support in emergency settings provide gui-
dance to prevent and manage mental health
problems and psychosocial well-being among staff
and volunteers (IASC 2007, action sheet 4.4, pages
87–92). Many of the same principles of staff care
have also been described in the Antares guidelines
(Antares Foundation 2012), and in agency-specific
guidance for staff mental health and psychosocial
support (Welton-Mitchell 2013). These guidelines
recommend that humanitarian agencies have written
policy in place, screen and assess staff before every
assignment, provide training and prepare staff for an
assignment, monitor staff, and provide ongoing sup-
port during the assignment. In case a crisis occurs
(i.e., hostage taking, medical illness, shooting, attack
on the compound, etc.), the agency should be pre-
pared to provide specific interventions as needed.
Immediately after the assignment is over, the agency
needs to actively assist with the reentry process of the
staff member. The agency should keep in contact
with the staff member even after the end of the
assignment and offer any additional support if
necessary.
International Humanitarian Aid Workers
Based on the result of a longitudinal study among
international humanitarian aid workers (Lopes
Cardozo et al. 2012), organizations deploying aid
workers should consider the following policy recom-
mendations for maximizing staff wellness:
Prior to Deployment
• Screen aid workers for history of mental illness
and family risk factors
 Chapter 28: Mental Health

• Provide stress awareness and stress management

Of the workers in
training
Uganda Jordan Sri Lanka
During Deployment 50% 25% 51%
• Providing the best possible living experienced five or more categories of traumatic
accommodations, workspace, and reliable events
transportation 68% 55% 58%
• Having an organizational policy and management high levels of symptoms of depression, anxiety, and
structure in place to ensure a reasonable workload, PTSD
adequate management, and recognition for 53% 50% 53%
achievements diagnosis of anxiety

During and After Deployment 26% 19% 19%

• Stimulate support networks which have shown to
be very important mitigating factors
• Connect with family and friends back home
(expatriate aid workers)
The organization should encourage:
• Involvement in social support
• Facilitate peer support networks by helping to
organize them
• Institute liberal telephone and Internet use
policies, paid for by the organization, which will
help increase social support networks of deployed
staff
National Humanitarian Aid Workers
Few studies have explored the consequences of the
stress of humanitarian aid work among national staff
(employees who are drawn from the local popula-
tion). Even though national staff far outnumber
expatriates/international staff and make up the major-
ity of the workforce in many humanitarian organiza-
tions, entitlements to services, including basic
healthcare, psychological support, medical evalua-
tion, salaries and other benefits, organizational sup-
port structures, and security policies for national staff
are generally less comprehensive than for expatriate
staff (McCall and Salama 1999). In addition, national
staff have often personally suffered traumatic experi-
ences and extreme stress related to the humanitarian
emergencies in their countries (Lopes Cardozo et al.
2005, Lopes Cardozo and Salama 2001).
In a series of three cross-sectional surveys, the men-
tal health of local staff was examined in Uganda, Jordan,
and Sri Lanka, (Ager et al. 2013, Eriksson et al. 2012,
Lopes Cardozo et al. 2013). In these studies, local staff
reported high levels of exposure to chronic stressors
related to both setting and work environment.
diagnosis of depression diagnosis of PTSD
From the results of the field surveys in these
three countries, the following generic recommenda-
tions to national humanitarian organizations for
their workers have been extracted. These
recommendations are relevant to organizations
that employ national staff in humanitarian emer-
gencies in other countries. The recommendations
include:
• Teach stress-management techniques as a regular
part of staff training
• Fortify social support mechanisms, including peer
support networks
• Avoid excessive hours spent at work and provide
adequate down time
• Practice good management principles, offer
specialized training to managers to increase the
skills necessary for their work: project planning,
time management, motivating staff, and assessing
and providing corrective feedback on
performance
• Provide continuing education on mental health
issues, while raising awareness that the issues can
apply to everyone, including staff
• Create access to psychological support for all staff
• Decrease chronic stressors related to the
workplace
• Provide psychosocial skills training and
a sustainable support system to aid the staff in
their work with beneficiary populations
• Address the high levels of depression and anxiety
symptoms in these workers
Conclusion
Mental health in humanitarian emergencies is a signifi-
cant issue that needs to be addressed. Currently, most

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 Section 3: Illness and Injury
mental health interventions in humanitarian emergen-
cies are based on best practices and empirical evidence
rather than evidence-based research. More research is
needed to improve the standard of care. Humanitarian
organizations must include mental healthcare of their
staff in standard organizational policies.
Notes from the Field
Kosovo (1999)
After a decade of violent conflict in Kosovo, there
were many anecdotal reports about mass rape of
women by Serbian troops. An international NGO
decided to send a psychiatrist from a European
country to assist the rape victims with any mental
health problems. The program consisted mainly of
counseling of rape victims. This seemed to make
sense because there was a lack of mental health
professionals in Kosovo at the time. However,
the international psychiatrist did not speak
Kosovar Albanian. Even though this was a well-
intentioned effort, several things went wrong
including:
• There was no communication with the mental
health professionals in Kosovo who were starting
up a training program at that time, so the whole
approach lacked sustainability. After the
international psychiatrist left, there was no follow-
up care in place for the women
• Since the international psychiatrist did not speak
the local language, the use of an interpreter was
necessary, and it was difficult to communicate
with the women
• Because the counseling took place in a building
that was clearly marked for survivors of rape,
other people in the community knew who was
being treated there and for what reason, which
stigmatized the women in a country where victims
of rape can become outcasts in their family
• An opportunity was missed to build capacity of
local staff
• The effectiveness of a counseling program for
women who have become victims of mass rape has
never been evaluated.
From this experience, there were several lessons
learned:
• First do no harm – identification of women who
have been raped could place them at risk in some
cultures
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• Integrate mental health services from
international organizations during an emergency
into existing services or train local (mental) health
professionals.
Acknowledgements: Nicholas DiStefano, Ha
Young Lee, Cole Youngner, Julia Smith, and Justin
Williams
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