My colleague and I prepared this letter for our local psychiatrists group and I share here. The affiliation is for our identification only. We are solely responsible for the content and no policy or official statement is represented.
EBOLA MENTAL HEALTH ? NOW IS THE TIME TO RATCHET UP THE CALM.
On Oct 14, 2014, a mental health professional publication ( Psychiatric News) reports on the state of mental health services in Liberia in the midst of the Ebola outbreak. They interview the only psychiatrist in the country of 6 million people and in the course of the interview he opines that while the most important immediate action is to control the epidemic, mental health professionals will be needed to help in the aftermath. In related news that day the WHO projects that new cases of Ebola in West Africa will soon exceed 10,000 per week. On October 15, 2014 Texas Presbyterian Hospital reports that a second health care worker has been confirmed with Ebola virus disease. This is very significant in this context: while the 6 very close (then unprotected) contacts of symptomatic Mr. Thomas Duncan have no report of illness, yet 2 protected health care workers in a tertiary hospital have contracted the disease. Cumulative data suggests that person in contact with very sick patients with Ebola are at far higher risk of contracting the illness. Ebola has now demonstrated human to human transmission on 3 continents and is in a pre-pandemic phase of spread.
So far the American media response to Ebola in the US has been alarm, critique, rumination and some dissemination of information. The official American public health response has been ?don?t worry,? ?it cannot happen here?, ?we can control it,? ?it is hard to control,? and ?we are considering modifying the care protocols.? The message on October 14 was that every hospital in America must prepare to treat patients with Ebola. On October 16, the message changes to only specialized clinics can treat Ebola but every clinic and hospital must have the ability to screen, identify and transport patients suspected of having Ebola to such clinics.
Now is the time to ratchet up the calm. Given the threat of a true pandemic afflicting millions of people, we do not wait until patients are in the hospital to start public health interventions. Likewise, we should not wait until after the pandemic to support mental health needs. In fact, aggressively supporting mental health resiliency now will not only diminish the psychological disability later, but actually improve the mitigation actions to decrease morbidly and mortality in the present.
We digress to describe 10 observed Ebola related mental health dysfunctions. By recognizing these dysfunctions we can correct them and act more effectively.
1. Ebola denial dysfunction - ignoring any threat from the Ebola pandemic
2. Ebola don?t know (repressive) dysfunction ? knowing of the threat but not attending to available information for empowerment
3. Ebola delegation (displacement) dysfunction ? knowing there is a threat and having information on the need but delegating to others all responsibility for preparedness actions ? this is the most commonly observed dysfunction
4. Ebola depressive (defeated) dysfunction - understanding the potential for catastrophic impact but pre-emptively surrendering to futility for impacting the outcome
5. Ebola obsessive dysfunction - in this dysfunction we learn all the details about this Ebola outbreak and every other outbreak and all the potential interventions and cures but we do not have a filter for rational effective action
6. Ebola panic dysfunction ? this is the sudden recognition of a threat from Ebola and a excited disorganized set of responses more for the sake of action rather than a reasonable expectation of success. Here the drama of the response is more important than the effectiveness.
7. Ebola paranoid dysfunction ? here the threat is seen from outside, from others with a mandate to scapegoat others into deserved suffering in order to save ourselves.
8. Ebola psychotic dysfunction ? by its very nature, psychosis implies impairment in reality testing in the spheres of threat assessment, rationality of actions, or consequences of actions. The behaviors here range from superstitious rituals to poisonous cures, or a unitary embrace with the inevitability of spread of illness to all others.
9. Ebola sociopathic dysfunction - this involves the thinking that one can manipulate the spread of Ebola virus disease for personal gain.
10. Ebola rationalization dysfunction - here is an overreliance of ?reasonable expectations? informed solely by our belief of what others should do rather than informed decisions based on actual behaviors of others.
In order to ratchet up the calm for ourselves and others, we, as mental health professionals and as health care professionals, must embrace professionalism in the face of dangerous uncertainty. We must empower the population and avoid empty assurances.
The adaptive responses of professionalism are manifested by
1. Awareness ? systematic acquisition of knowledge about what is known and unknown about Ebola virus disease and the characteristics of this epidemic. Know that especially for this Ebola crisis, our communities are rapidly adapting their health response based on what we learn about the illness. Having a protocol is essential, but it is important to recognize that the protocols will change based on new information.
2. Dual use ? plan and act in ways that are useful not only for a specific Ebola encounter but can be generalized to other threats or daily challenges - The team work and skills we have in place now will help with Ebola now and then will help with our other community health problems in the future.
3. Focus ? the media and casual conversation about us can be very distracting. We need to be aware of the other activities but do not sacrifice what we can do to discuss what others are not doing.
4. Humility ? the key portion of awareness is to be aware of what you do not know. This is not a free floating anxiety of the unknown but more the scientific curiosity of how this works.
Some simple examples are questions like ?
a. What is the viral load at different phases of exposure infection and disease progression of illness ?
b. What are the key host variables in defending against the illness or contributing to the morbidity of the illness ?
c. In the afflicted populations, can we detect antibody evidence of exposure in persons without a history of disease ?
5. Humanity ? this is our core dual use function. As persons we have chosen a path in service to others. Also as persons we have to acknowledge our own needs and responsibilities. We have plans for our families to be cared for while we are at duty. Our duty calls upon us to serve in spite of the risks.
For epidemic control, mental health personnel have an essential role in risk assessment, risk communication, operational stress management, crisis counseling and specific mental health treatments. Now is the time for mental health to join the preparatory teams to mitigate Ebola.
Joseph E. Thornton, M.D.
Rajiv Tandon, M.D.
Department of Psychiatry,
University of Florida College of Medicine
