In a commentary appearing in the June issue of the journal Biosecurity and Bioterrorism, faculty from the Johns Hopkins Berman Institute of Bioethics say that more attention should be devoted to triaging and managing those already identified as having mental disorders.

This group must be given just as much consideration during the planning stage as is given those who will have physical injuries and more obvious anxiety-related reactions, such as post-traumatic stress disorder (PTSD).

"Disasters limit the availability of resources, and these groups are especially vulnerable because they cannot advocate for themselves," says Peter Rabins, M.D., M.P.H., a core faculty member at the Berman Institute.

"But little attention has been given to the ethical challenges that arise when resources are limited, to the importance of identifying these ethical issues ahead of time, and for establishing mechanisms to address these moral dilemmas."

In the article, Rabins and Nancy Kass, Sc.D., the Berman Institute's deputy director for public health, say that many of the mentally ill are dependent on caretakers and aren't fully capable of making sound decisions on their own.

Emergency planners are ethically obligated to ensure that immediate and adequate mental health services are provided alongside more traditional triage, the bioethicists state.

"Disaster-response managers and those on the front line are well aware that survivors may succumb to PTSD and other mental disorders," says Rabins, the Richman Family Professor for Alzheimer's and Related Diseases at the Johns Hopkins University School of Medicine. "But sudden devastation also puts people with both lifelong and acquired intellectual disabilities in grave danger as well."

Whether a disaster is natural, as in an earthquake, or is caused by man, as in war, the ethical obligation to treat those with mental disabilities in the aftermath is just as important as aiding those with flesh wounds, Rabins says.

One study the authors cite found that 22 percent of Hurricane Katrina survivors who had pre-existing mental disorders faced limited or terminated treatment after the disaster.

Beyond patients with dementia and others who are mentally impaired, the authors say that this vulnerable group includes those who suffer from chronic pain and may be dependent on opiates, as well as substance abusers who receive treatment in the form of powerful sedatives classified as benzodiazepines. Withdrawal can be life threatening, the authors note.

The authors acknowledge that drug and alcohol addicts are often seen as unworthy of focused attention during a state of emergency-and scarce resources-because their condition is widely perceived as "self-inflicted."

But distinguishing between conditions that individuals have or don't have control over "is neither practical nor ethically justifiable, and in emergencies becomes wholly impractical," the authors assert.

Recommendations
As a first step, the authors recommend that disaster-response planners proactively identify and anticipate what needs might arise by meeting with clinicians and public health officials. Those discussions would then guide comprehensive advance planning.

Because licensed practitioners will likely be scarce immediately after a disaster, planners should consider training emergency medical technicians (EMTs) and other first-responders to identify those with pre-existing mental conditions and recognize those in need of prompt attention.

Acknowledging that first-responders may also be spread thinly post-disaster, the authors also suggest that planners consider turning to volunteers from the community, such as religious leaders and trained civilians, to distribute basic materials and temporary services to at-risk individuals.

To further make the best use of limited resources, the authors say that broad-based primary interventions, such as psychological debriefings, might be a lower priority than implementing potentially more effective "secondary prevention" measures, which seek to reduce long-term ill outcomes.

In particular, EMTs could be asked to responsibly distribute sedatives to manage short-term anxiety-related symptoms. But the authors say that policies would need to be developed to expand the list of those authorized to prescribe such drugs, as they are at present strictly regulated by federal law.

The authors note that sedatives were distributed in New York City immediately after the Sept. 11, 2001, terrorist attacks.

Ethical challenges
The authors also recommend that planners focus on ethical challenges likely to arise when assisting the mentally disabled during and after a disaster. These challenges may be partially addressed by adopting a "crisis standard of care" consistent with guidelines from the Institute of Medicine, they say.

Special attention should be given to assisted-living and long-term care facilities that house many residents with significant cognitive impairment, such as dementia. If these people are forced to evacuate, they may not fully comprehend the crisis and may be at risk for extreme emotional distress.

Hence, disaster-preparedness training for first-responders should also include information about how to interact with such individuals in a way that respects their dignity, the authors say.

More broadly, criteria for priority setting and the allocation of scarce resources can be based on objective factors, such as the likelihood of response to intervention, the prevention of chronic health problems, and the impact on public safety, the authors explain.

In addition to Kass, the other co-authors of the commentary are Lainie Rutkow, J.D., Ph.D., M.P.H., an assistant professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health; Jon Vernick, J.D., M.P.H., an associate professor in the Department of Health Policy and Management at the Bloomberg School of Public Health; and James Hodge, Jr., J.D., a professor of health law and ethics at Arizona State University.

The commentary, "Challenges for Mental Health Services Raised by Disaster Preparedness: Mapping the Ethical and Therapeutic Terrain,".

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