Recovering from the Canterbury earthquakes : evaluation of a specialist mental health service initiated for the treatment of severe and ongoing earthquake-related distress.
Most people exposed to disasters cope well. Others, however, develop posttraumatic stress disorder (PTSD)–a mental disorder characterised by symptoms of intrusion, avoidance, and hyperarousal–requiring input from specialist mental health services. To date, relatively little research has evaluated these services, and less is known about characteristics of people seeking treatment and their treatment outcomes. In 2010 and 2011, a series of major earthquakes occurred in the Canterbury region of Aotearoa New Zealand, resulting in initiation of the Adult Specialist Services for Earthquake Trauma Treatment (ASSETT) service to provide cognitive behavioural therapy (CBT) for people with earthquake-related PTSD or subthreshold PTSD symptoms. The current research used systematic literature review methods, in conjunction with data collected from people seeking treatment with the ASSETT service, to address issues relevant to the development of disaster mental health responses, particularly specialist mental health services. A systematic review was conducted synthesising research examining mental health service use among adults exposed to natural disasters. A second systematic review and meta-analysis evaluated psychological interventions for earthquake-related PTSD. A series of studies then utilised diagnostic interview and self-report data collected from people seeking treatment with the ASSETT service (n = 184). Data were collected on factors relating to sociodemographics, pre-earthquake mental disorders, current psychological functioning, degree of objective and subjective earthquake exposure, and life events. These studies examined factors distinguishing treatment-seeking participants from earthquake-exposed Canterbury residents who coped well; differences associated with different prior mental disorders and timing of treatment presentation; and outcomes of CBT provided by the service. Four overarching themes emerged across study findings. The first related to the role of objective and subjective disaster exposure in the development of post-disaster mental health outcomes. Subjective peritraumatic responses were found to be an important factor distinguishing treatment-seeking participants from those who coped well following the earthquakes, independent of objective exposure severity. Heightened peritraumatic responses were also associated with poorer treatment outcome, although not beyond their association with pre-treatment PTSD severity and degree of comorbidity. The second theme related to the role of pre-trauma mental health in the development of post-disaster mental health outcomes. Participants with a history of pre-earthquake mental disorder presented with more comorbid disorders than participants with no prior disorder, but reported comparable degrees of PTSD severity and similar treatment outcomes. The third theme related to temporal considerations for disaster mental health responses. Participants who presented at later time points tended to be older and were more likely to have subthreshold PTSD symptoms, but had similar treatment outcomes as those who presented at earlier time points. The fourth theme related to treatment of severe and ongoing earthquake-related distress. CBT without a formal exposure component was associated with clinically significant improvements on a range of outcome measures, with group and individual-based treatment associated with comparable outcomes. Findings of the current research suggest people seeking treatment for severe and ongoing disaster-related distress are not homogenous, and are likely to present for treatment at different time points, have varied mental health histories, and report diverse disaster experiences. CBT is an effective treatment for severe and ongoing post-disaster distress when delivered in real-world mental health service settings. Group CBT represents an efficient, scalable, and effective treatment format for post-disaster distress, and may be an attractive option for treating widespread need using limited resources.