Unmet Psychosocial Needs of Disaster Survivors in India: A Growing Concern

Many disaster survivors suffer from stress-related mental illnesses and related disabilities, and in a proportion of them, the morbidities continue long-term. However, most of the post-disaster mental illnesses are not even identified or treated. These affect the recovery and socio-occupational functioning of the survivors. There is an immense need to address the psychosocial needs of disaster survivors in India, which frequently experiences various types of disasters, ranging from severe weather events to human-made and industrial disasters. Despite the knowledge base of post-disaster psychiatric morbidity, the existence of mental health services, the psychosocial support of survivors remains largely unmet, uncoordinated, and unattended. In this context, it is essential to explore what the concerns are in disaster-mental health support; where are the gaps, the reasons behind them, and what can be done.

Discussion

The Concerns

There are frequent extreme weather events, human-made, and industrial disasters in India. Most of the disasters affect a sizeable proportion of the population. The majority of survivors usually receive immediate medical care for physical injuries and some financial compensation after the traumatic incidents. On occasions, a proportion of survivors get counselling and other psychological support that remains confined to the immediate post-disaster phase. However, most of the support seems to end here. It is known that, depending upon the trauma intensity and individual context, a considerable proportion of affected people suffer from long-term mental health problems that require multidisciplinary support. If the disaster trauma is associated with life-changing physical injuries and disabilities, the challenges get compounded.

Higher Mental Health Needs of Survivors

The higher mental health needs of the disaster-affected population compared to the general population have been reported ¹ ; however, it is not clear whether the mental health service use by the disaster survivors increases, and this is an area for exploration. It is understandable that following the traumatic experiences of disasters, the linked physical and psychiatric illnesses and disabilities, changes in psychosocial environment, and specific occupational challenges,^2,3 some survivors have multiple needs requiring long-term intervention and rehabilitation. However, in reality, only a proportion of survivors receive a basic level of psychological support in the initial phases, if at all, in the form of counselling, mostly by lay counsellors or local volunteers following training ² ; psychological support from professionals, even for those who have complex post-disaster mental health issues, is often hard to find in many areas. ⁴ These factors suggest that a considerable proportion of the affected population requires trauma-specific psychosocial support; however, most do not get it. There could be various reasons behind this.

Gap in Knowledge Base

Most Indian research on post-disaster mental health is focused on the acute phase, and there is scant literature in India about the long-term mental health consequences of disasters. The immediate post-disaster studies report depression, anxiety, post-traumatic stress disorder, complicated grief, and substance use disorders, etc.,^5–7 as in other parts of the world. Similarly, children and adolescents are a more vulnerable group, with non-specific symptoms, anxiety disorders, school refusals, scholastic decline, conduct problems, depression, and post-traumatic stress disorders. ⁶ Most of the survivors have multiple psychiatric morbidities. A large number of survivors have subsyndromal symptom, ⁶ which could also impact their optimal functioning.

Long-term Consequences

Considering long-term consequences, one study after 4.5 years of the 2004 tsunami reported that a considerable proportion of victims had anxiety (23.1%), depression (33.6%), PTSD (70.9%), and comorbidity (44.7%). ⁸ It is well known that a proportion of the disaster survivors continue to have long-term mental health problems, ⁹ and repeated exposure has worse mental health outcomes. ¹⁰ While India experiences repeated disasters, it is probable that the morbidities are high in affected communities and individuals. The extent of the continuing morbidities needs to be established through follow-up and longitudinal studies. As an example, although there was some understanding of the acute mental health consequences of the COVID-19 pandemic, ¹¹ exact nature of its continuing impact on mental health is largely unknown.

Lack of Clarity on Resilience Factors

Besides the lack of adequate research on long-term consequences, another area that is not well researched is the coping strategies and resilience factors of the survivors following disaster experiences, both at the individual and community levels. It is known that survivors utilise or develop their coping strategies, or participate in the community and cultural coping methods. ² There is a great deal of acceptance of stressful situations and their consequences by people through various cognitive, emotional, sociocultural, and spiritual strategies.^12,13 These are effective in managing stress symptoms; however, these would need specific studies, and the understanding may help to incorporate these strategies for interventional measures.

Unmet Psychosocial Needs

Undiagnosed and Untreated Mental Illnesses

Despite increased awareness in India about post-disaster mental health consequences and methods of intervention,^6,14 at a professional level, considerable proportions of disaster survivors with psychiatric problems in the community remain undiagnosed and untreated. The know-how about identifying and supporting disaster survivors at the community and primary care level needs to be improved.

Socio-occupational Impairments

Furthermore, it is not just the mental health consequences that the survivors need support with. For various reasons, including the impact of mental illnesses, their occupational functioning gets impaired as well, ³ and the survivors would need multidisciplinary support, which usually remains unattended.

Support for Indirect Victims and Communities

Besides the survivors, sometimes their family members, as indirect victims, also bear the brunt of the disasters. Multiple members of the same family or neighbourhood suffer the consequences, which might impact their collective functioning as a community. This community would need long-term support. The nature of the community’s need and support following disasters has not been studied adequately.

Reality Gap

In an ideal scenario, psychosocial support should be integrated into the usual health and social care system. It would be expected that the survivors would receive appropriate care available through these existing systems. However, this is not always the case, as the long-term component of the psychiatric intervention is often overlooked, even in developed nations.

The situation in India is alarming, as most of the needs are not identified, and in cases where these are identified, they are not addressed adequately, ⁴ or it takes a considerable period to arrange for any support, if any. As an example, even decades after the Bhopal Gas tragedy, the survivors did not receive appropriate mental health and rehabilitative care, and the challenges continued. ¹⁵ After the 2023 train collision in Odisha, only a proportion of survivors received psychological intervention ¹⁶ ; there was no specific support for others.

There is hardly any information regarding psychosocial support to victims of riots, terrorism, biological disasters, and other human-made disasters in Indian settings. While it is possible that some of the victims sought intervention on their own, there was no information on strategic support. These issues highlight that following disasters, survivors do not get adequate treatment and care.

Reasons for Unmet Needs

There are various reasons for the inadequate or almost non-existent impetus for the psychosocial needs of disaster survivors. Understandably, one of the reasons might be the sheer number of people that are affected in major disasters, and the existing systems are overwhelmed, with no scope for arranging adequate support. That is usually the case in crises; however, later, as the situation settles, a lack of any mechanism to continue support is another reason.

There is no established process to systematically assess the changing psychosocial needs following disasters, the functional disabilities, and the support needs. In addition, there is usually no system of follow-up about these issues affecting the survivors. It has been observed that the post-disaster mental health support has been primarily outreach or counselling, ¹⁴ weeks or months after the disaster, which reaches only a small proportion of survivors. Most of the survivors are left mainly to their own devices to arrange for their support, without even educational information about the nature of the problem and the support available.

In addition, scant research on the long-term consequences of disaster trauma does not help to highlight the continuing needs of the survivors. There is also a lack of research focusing on the impediments to the recovery of the survivors. This leads to inadequate awareness about the long-term needs of the survivors, the benefits of psychosocial support, and their effectiveness. These might contribute to inadequate action by both professionals and authorities in varying degrees.

Beyond the treatment of stress-related mental illnesses, any specific assessments for mental health disabilities, occupational, and rehabilitative support are almost non-existent. When appropriate, there is a need to study the impact of mental health disabilities on the functional capabilities of disaster survivors, taking into account other contributing factors in post-disaster situations. In addition to the above, there are hardly any facilities or approaches observed in the usual mental health care systems in India for disaster survivors.

In addition to the above, lack of public awareness about the stress responses and their impact on the lives of survivors could probably be a contributing factor to inadequate impetus in this area. In many cases, despite awareness and suffering, many people do not access mental health services for other reasons, such as availability, accessibility, and stigma. ¹⁷ This continues to be a significant issue related to mental health service provision in India, where professionals and services are primarily concentrated in larger towns and cities. In contrast, rural residents are more vulnerable to the impacts of disasters. ¹⁸

While it is primarily a lack of awareness and scarcity of funds in developing countries, lack of focus on these areas by the authorities is also a contributing factor in countries with well-established care systems.

Actions to Support the Survivors

Preventive Measures

Before discussing the unmet needs and required interventions for the survivors, it is important to highlight that many actions can be taken to prevent disasters or decrease their impact. These will be far more helpful than the arranging intervention for a large number of people affected. There are many examples, such as improved warning systems for extreme weather events, heightened preparedness, effective evacuations and supportive shelters ¹⁹ ; appropriate safety checks for industries; and adequate mechanisms to pre-empt and prevent human-caused disasters, etc.

Preventing stress symptoms from developing into psychiatric illnesses after trauma exposure is another important area for research. It has been reported that adequate, timely, practical, emotional, and social support helps in coping and might decrease the chance of stress-related disorders. ²⁰

Screening and Triaging

It is essential to set up an appropriate assessment system to check the impact of the disaster on the mental health of the survivors. This may include short screening in the immediate post-disaster period to identify more vulnerable survivors who might go on to develop syndromal psychiatric disorders. ²¹ Later screening can be holistic to identify disorders and disabilities requiring specific support. In addition, changes in the post-disaster environment hindering the recovery of the survivors to their previous level of functioning need to be evaluated.

Individualised Care Plan

Depending on the mental health conditions and disabilities, it is important to develop an individualised care plan to facilitate recovery. This support plan should be comprehensive, taking into account a biopsychosocial approach. The usual psychosocial management approach involves crisis support, post-crisis continuity of individualised support, and mainstreaming the care. ⁴ Once survivors with specific psychological needs for continued care are identified, these can be followed through various means. It can be facilitated through local services if available, online counselling support and psychotherapies, through their employing organisation, mental health charities, or referral to secondary or specialised services. The process could be coordinated centrally through case managers or organisations until the individual’s recovery needs are met. ⁴ This should also involve support related to getting back to work, finding suitable employment, and support to sustain work.

Integrate Primary and Secondary Care

It is important to integrate primary and secondary care along with social services, non-governmental organisations, and employing organisations to work towards delivering the individualised support plan and care pathway, indicating the specific support and the professionals involved. The requirements would usually involve professionals from psychiatry, mental health nursing, counselling/psychotherapy, occupational therapy, employment support, social services, appropriate non-governmental organisational support, etc. Training primary care professionals, accredited social health activists (ASHA), local non-governmental organisations, and local volunteers in crisis and stress management, bereavement counselling, identification of clinical risks, and criteria for referral to secondary services, ³ might help, as more vulnerable survivors are usually in the community with limited access to secondary mental health services.

Long-term Follow-ups

Periodic and long-term follow-ups are required to know the progress and outcome of the interventions. There is a need for research alongside the care provided to explore the effectiveness of interventions provided in the recovery of the survivors. This will also guide future disaster support planning and strategies.

Community Level Support

Along with these, it is of paramount importance for authorities to support and develop resources locally to support the survivors, working jointly with the professionals and survivors. There has been tremendous progress in disaster management in India with dedicated agencies.^19,22 The support should be effectively extended to include psychosocial care in the short and long term. The approach of psychosocial needs should primarily focus on a community level, considering the number of people to be supported. Some survivors would need community-based rehabilitation and interventions. Communities can be strengthened to prepare well for disasters and develop group coping strategies that can support resilience. In addition, there should be opportunities and explicit processes to access the secondary level of care when required.

Policies and Strategies

Regional and national policies and strategies of disaster management should emphasise the psychosocial needs of the disaster survivors. The psychosocial support should be an integral part of the disaster management plans, policies, and strategies, with adequate short- and long-term support. The strategies to be considered comprehensive and complete should specify how these can be met, and have an adequate budget allocation. For the policies and strategies to be effective, joint working between professionals and authorities is required to focus on this relatively neglected area in the support of disaster survivors.

Conclusions

While appropriate, timely actions may decrease the mental health impact of the disasters to an extent, many survivors suffer from disabling psychiatric illnesses with complex psychosocial needs that require long-term care. It needs to be highlighted that the psychosocial needs are not adequately identified and met currently in the existing systems of health and social care services. These concerns should be recognised, form a part of the overall local and national disaster management strategy, and should have clarity in the process of providing the support and the necessary budgetary allocations. The post-disaster support should be integrated into the existing health and social care systems so that survivors receive seamless, continuous care, rather than just crisis support after their catastrophic experience. There is a need for further research on the protective/preventive role of early interventions, the long-term mental health impact of disasters, cultural coping and resilience factors, and effective ways to provide psychosocial support to affected masses.