Jul 24, 2019
Ritchie, MD, MPH, talks with Lorenzo
Norris, MD, host of the MDedge Psychcast and editor in chief of
MDedge Psychiatry, about averting disruptions in psychiatric
medications after short- and long-term disasters.
Dr. Ritchie is a psychiatrist who works in Washington.
Show Notes by Jacqueline Posada, MD, 4th-year resident in the
department of psychiatry & behavioral sciences at George
Washington University, Washington.
Later, in the “Dr. RK” segment, Renee Kohanski, MD, discusses the
potential impact of pharmacogenomics on the practice of psychiatry.
Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory
Board, is a psychiatrist in private practice in Mystic, Conn.
Dr. Ritchie and disaster psychiatry
- She entered disaster psychiatry through her many years as a
- She had to think about how to plan and treat psychiatric
emergencies during deployments to an austere environment, such as
Somalia and Iraq.
- She was on active duty during Sept. 11, 2001, and helped
coordinate the disaster response during that period and then
completed a fellowship in disaster
psychiatry at the Uniformed Services University in Bethesda,
- Ritchie says that the field has changed immensely, from the way
in which it once handled debriefings to the current use of
psychological first aid. Yet, she thinks that psychiatric
medications are a neglected area of planning.
Minor, major disasters can cause disruptions in
- Access/continuity of psychiatric medications is overlooked in
- Disruption in psychotropic medications will affect many
populations, including people with serious mental illness (SMI),
first responders, and patients dependent on controlled substances
such as methadone, buprenorphine and naloxone, and benzodiazepines.
- Especially for those with SMI in a disaster that creates
increased stress, the absence of medications can have longer
negative consequences, such as changes in behavior as
hospitalizations or that may lead to contact with the legal
- Plans need to be made in advance with patients to prevent
disruption in medications.
- Small disasters could include a weather event, such as a snow
or rainstorm. These can create barriers to medication at the basic
level, such as a lack of electricity affecting computer systems, a
pharmacist cannot make it to work, etc.
- Larger disasters, such as hurricanes, can have effects that
last months to years, such as loss of psychiatrists or lack of
other infrastructure related to mental health.
Population-specific planning during
- Patients with SMI: Some might be homeless and affected by
weather conditions; there often may be a robust citywide response
aimed at creating a safety net for these individuals.
- First responders: It is essential to have medications available
for sleep, such as trazodone or zolpidem, to mitigate the effects
of long, stressful workdays that make it hard to “turn off” and get
- Working professionals: Many people balance busy lives on a
routine basis, so it’s important to help these patients maintain
their medications and functioning. Psychiatrists should make sure
that these patients have adequate supplies of medications, such as
How can psychiatrists help to prepare?
- They can ensure that patients can have an adequate supply of
medications in several locations in case of disaster or
- They can provide a 90-day supply of medication in the event of
a large disaster with lasting effects.
- They can determine that patients have a printed up-to-date list
of all their medications in case they need to change pharmacies or
have medications refilled by another clinician, such as a primary
- Patients and doctors rely on the electronic health records for
medication lists, which may fail during a disaster.
- They can identify at-risk patients, such as those on controlled
substances (opiates and benzodiazepines), and refill any
medications that, if missed, can result in withdrawal
Disaster planning has come a long way over the last 30
- Disaster planning often takes into consideration food supply
and medications. However, psychiatric medications often are
forgotten as being essential to patients.
- For example, the Centers for Disease Control and Prevention
does not stockpile psychotropic medications, other than valium, for
- Psychiatrists can advocate within their cities or states to
ensure that disaster plans include a contingency for psychiatric
care, such as stockpiles of psychotropic medications.
- Psychiatrists can help in disaster planning by consulting on
formularies for disasters and suggesting versatile psychotropic
medications that can be used in multiple settings or for different
- Examples of versatile medications include mirtazapine for sleep
and depression, bupropion for depression and ADHD, medications for
sleep, antipsychotics, and such key SSRIs as fluoxetine.
- Psychiatrists also must plan for themselves and consider their
own self-care as well as emergency planning for their offices and
Ritchie EC et al. When a disaster disrupts access to psychiatric
Current Psychiatry. 2019 May;18(5):22-6.
Kenardy J. The current status of psychological debriefing: It
may do more harm than good. BMJ. 2000
Rodriguez JJ and R Kohn. Use of mental health services among
Curr Opin Psychiatry. 2008 Jul;21(4):370-8.
Redd SC and TR Frieden. CDC’s evolving approach to emergency
response. Health Secur. 2017
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