Assessment of psychiatrists’ preparedness in managing disaster-related psychiatric disorders: a survey in Taiwan from post-graduate medical education perspective

Background Disaster-related psychiatric disorders (DRPD) present a significant challenge to mental health professionals, yet there is a notable lack of emphasis on the preparedness of psychiatrists in managing these conditions within post-graduate medical education. Methods This study utilized a questionnaire to collect data from psychiatrists, focusing on their prior involvement in managing DRPD, perceived competence, medication preferences, and factors influencing their experiences in handling such disorders. Analysis included distribution and ranking of variables, alongside cross-analysis examining associations between demographic factors (age, gender, hospital levels, years of practice, board certification) and treatment experiences, as well as readiness for in-hospital or outside-hospital mobilization in DRPD management. Results One hundred and three Taiwanese psychiatrists participated in the study, with the majority reporting involvement in managing DRPD (71.8%), particularly in post-traumatic stress disorder (PTSD) and depression. Antidepressants, specifically serotonin selective reuptake inhibitors, were commonly preferred for DRPD treatment, including PTSD and depression. Psychiatrists aged over 40, with more than 10 years of practice, and hold the board-certified status, showed greater experiences for outside- or inside- the hospital mobilization in DRPD management. Conclusion Findings suggest that within post-graduate medical education, Taiwanese psychiatrists demonstrate significant experience, willingness, and capacity to effectively manage DRPD. However, there is a need to integrate comprehensive training on disaster psychiatry into post-graduate psychiatric education programs to further enhance preparedness and optimize outcomes in managing these challenging conditions.


Introduction
Disasters, characterized by their unpredictability and capacity for causing death, trauma, and property destruction (1), affect millions globally each year.The frequency and impact of these events are escalating due to climate change and population density growth (2), defining disasters by three key characteristics of largescale traumatic events: significant harm or fatalities among a large group of people, societal disruption, and ensuing mental and physical health consequences (1,3,4).
The aftermath of disasters encompasses cognitive, emotional, and physiological responses, leading to predictable psychiatric morbidity (5,6).Beyond post-traumatic stress disorder, common mental health effects include distress, grief, anxiety disorders, and depression (5)(6)(7), for examples, from the exposure to natural (8) or deliberately caused (9) disasters.Individuals often resort to selfmedication, primarily with alcohol, risking harm and substance use disorders while delaying the recognition of mood and anxiety disorders (10).
The demands on psychiatrists differ significantly from routine clinical practice (10).Psychiatrists in hospitals must be informed about disaster plans and engage in planning processes, ensuring patients have crisis plans covering mental health management and accessing post-disaster treatment and medication (11,12).Rapidly mobilized mental health teams, equipped with specialized disaster mental health skills, play a pivotal role in disaster intervention (13).Psychiatrists, as responders, can lead multidisciplinary teams to organize post-disaster psychiatric care, providing crucial assessments and interventions (14).Hence, acquiring fundamental competency in disaster psychiatry is vital for every psychiatrist.
Post-graduate medical education emphasizes clinical training for healthcare professionals, which focused on the standardized training and, under senior physicians' guidance, develop independent healthcare skills for medical graduates (15,16).In Taiwan, psychiatric training also following the principles of postgraduate medical education as aforementioned (17,18), yet there's a shortage of training competencies incorporating perspectives from both high-and low-income countries (19).In addition, the training for psychiatric trainee might also influence the psychiatrists' preparedness (20).
Given the heightened risk for natural disasters in several Asian countries, notably by earthquakes, volcanic eruptions, typhoon, and cyclones (21), scant attention has been directed toward assessing psychiatrists' readiness in managing disaster-related mental health crises (13).This study aims to examine the readiness of Taiwanese psychiatrists in responding to disaster-related mental health crises.We hypothesize discrepancies among psychiatrists based on training in the post-graduate medical education duration and prior clinical experiences.

Study design and participants
This descriptive study employed an innovative questionnaire to assess Taiwanese psychiatrists' readiness in managing disasterrelated psychiatric disorders (DRPD).We distributed 103 questionnaires among Taiwanese psychiatrists in a cross-sectional approach.Inclusion criteria comprised psychiatrists practicing in Taiwan, completing the questionnaire autonomously, comprehending the study's objectives, and consenting to their questionnaire's use in the analysis by providing informed consent.The participants completed the self-administered paper-based the questionnaires.
All participants were exclusively Taiwanese, with no inclusion of a control group.Data pertaining to the general population were sourced from prior studies for subsequent discussions in both civilian (22,23) and military populations (24-26).The questionnaire collected demographic data, including gender, years of clinical experience in psychiatry, and practice facility type.A 5level rating scale assessed psychiatrists' preparedness when encountering disasters, gauging familiarity from high to low across several facets: participation in DRPD management, familiarity with disaster-related psychotherapy, acquaintance with medications for DRPD (e.g., PTSD, depression, anxiety, and sleep disorders), and willingness to be mobilized for DRPD relief efforts.

Statistical analysis
This study employed SPSS statistical software for documentation and analysis.Continuous variables were described using mean and standard deviation.Categorical variables were presented as frequency and percentage.Subjective perceptions of psychiatric drugs and psychotherapy for DRPD.Psychiatrists' emergency response to DRPD, long-term follow-up willingness, and mobilization readiness were documented using mean and standard deviation.Cross-analysis explored demographic associations with psychotropic medications or psychotherapy, long-term follow-up, and willingness to participate.T-tests, chisquare tests, variance analysis, correlation, regression, and other statistical methods were employed for verification and inference, with statistical significance set at p < 0.05.Multiple linear regression was also used in the assessment of the relationship between factors in unison psychiatrists' preferences and experiences, with statistical significance set at p < 0.05.

Results
A total of 103 psychiatrists participated in this study, with male participants, board-certified professionals, and those working in regional hospitals or medical centers comprising the majority (Table 1).Notably, 82.5% of these psychiatrists expressed varying degrees of intent to treat, follow up, and even be deployed for the management of DRPD within the scope of this investigation.
Among these psychiatrists, a significant majority-ranging from 74% to 85%-reported previous experience in treating various forms of DRPD, including PTSD, depressive disorders, anxiety disorders, sleep disorders, and other conditions such as conversion disorders, dissociative disorders, and adjustment disorders.However, only 24% had prior experience in external deployment for DRPD management, while 40% had experience with internal hospital deployment (Table 2).
Table 3 outlines the subjective confidence levels of psychiatrists regarding their competence in managing DRPD through psychotherapy.Across various conditions such as PTSD, depressive disorders, anxiety disorders, sleep disorders, and other related disorders, all participating psychiatrists involved conveyed a moderate level of confidence, in a 5-level rating scale, in their ability to conduct both individual and group therapies.
Regarding the choice of psychotropic medications for DRPD treatment, the majority of psychiatrists in this study leaned toward Selective Serotonin Reuptake Inhibitors (SSRIs) and benzodiazepines (for anxiolysis or sleep) (Table 4).Specifically, when addressing disaster-related PTSD, most preferred sertraline, escitalopram, and fluoxetine as their antidepressant choices (Table 4).
Table 5 presents data indicating that SSRIs, Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs), and Z-drugs/ benzodiazepines were the most frequently selected psychotropic medications for addressing disaster-related depressive disorders, anxiety disorders, sleep disorders, and other associated conditions.
Table 6 illustrates that psychiatrists with longer years of service (10 years or more) and holding board-certified status are associated with greater experience in managing DRPD and demonstrate a preference for specific mobilization locations, whether out of hospital or within hospital settings, for interventions, by the multiple linear regression analysis.Psychiatrists aged 40 or older exhibit more experience in managing DRPD, with statistically significant associations found for DRPD in general, particularly anxiety disorders, and both out-of-hospital and in-hospital intervention mobilizations.There is no discernible association between gender and hospital levels with regard to experience in managing DRPD.

Discussion
Disasters and public health crises pose multifaceted challenges, emphasizing the pivotal role psychiatrists play in addressing postdisaster psychiatric needs (11,13,27).This study represents the first exploration of disaster preparedness among Taiwanese psychiatrists and presents several notable findings.Primarily, a significant majority of these professionals exhibit substantial experience, willingness, and capability in managing DRPD.However, while many have treated DRPD, fewer have been involved in hospital deployments for DRPD management, signaling potential areas for improvement.
In Taiwan's psychiatric resident training, the clinical training program must contain the Suicide Prevention and Disaster Psychiatry Program (17).However, in the results of this study, the average of the participants' subjective feelings of competence in the 5level rating scales are between 1.91-2.97 in the psychotherapeutic methods for DRPD.Among these psychotherapeutic techniques, the lowest feelings of competence are group and individual psychotherapies.In addition, the 3 rd rank of medications chosen by psychiatrists for PTSD are benzodiazepine.However, benzodiazepines are better avoided the pharmacotherapy for PTSD (28-30).In the disaster psychiatric response, the interdisciplinary team is needed (31)(32)(33)(34).The post-graduate education about the disaster responses for nurses (35), psychologists/counselors (36, 37), and social workers (38) for disaster-related general and mental health services are also important.Therefore, the core competence in the training psychiatric residents is needed, in the post-graduate medical education.
The study notes a perceived lack of competence in utilizing psychotherapeutic approaches for DRPD.Core competence training in the postgraduate psychiatric education programs might enhance the subjective and objective competence in individual and group psychotherapies (39), even for the DRPD (40).
In this study, the deployment experiences of participants are associated with age, the length of practice, and board-ship in psychiatry.Incorporating real-world deployment experiences into postgraduate training might enhance psychiatrists' readiness and confidence in disaster response (41,42).
The variance in reported DRPD prevalence (ranging from 1.5% to 74%) in prior Taiwan-based studies may stem from methodological disparities, differing study populations, diagnostic criteria, and case definitions.This variance could also be attributed to Taiwan experiencing fewer wars and natural disasters compared to other regions.As a result, the populace might initially seek primary care providers over psychiatrists during disasters, highlighting potential gaps in popularizing disaster psychiatry in Taiwan (43).
Recent clinical guidelines underscore the efficacy of SSRIs and SNRIs in managing post-traumatic stress, recommending these  medications for eligible patients (44).Complementary studies have also highlighted the benefi ts of benz odiazepines or nonbenzodiazepine agents for disaster-related anxiety and sleep disorders (45,46).Correspondingly, the preference of Taiwanese psychiatrists for SSRIs, SNRIs, and Z-drugs/benzodiazepines aligns with international guidelines, indicating their substantial knowledge in managing DRPD through pharmacotherapy.Psychotherapy's significance in post-disaster mental health recovery cannot be overstated, especially in providing continuous psychological support (47)(48)(49)(50).Despite evidence favoring psychotherapy's efficacy over medications (51,52), our study revealed psychiatrists' perceived lack of competence in utilizing psychotherapeutic approaches for DRPD.This underscores the need for bolstering psychotherapy training among Taiwanese psychiatrists.

Limitations
This study's limitations include its cross-sectional nature, hindering causal inference, and the lack of differentiation in the questionnaire regarding special needs among different age groups, such as children and the elderly.Additionally, a low response rate might introduce non-response bias, potentially attributed to various factors like workload and insufficient incentives.Therefore, we admitted that non-response bias existed in this study.One potential way to solve this problem in enhancing post-graduate medical education, since several studies have proved that post-graduate medical education could enhance the for the manpower development and capacity building in academic and research competence (53), workers' skills in child and adolescent mental health (54), or providing culturally relevant and sensitive psychiatric training (55).Thirdly, in this study, we didn't conduct the competence of the knowledge in the psychiatrists for the international treatment guidelines for DRPD.Further studies for this competence in the psychiatrists are needed in the future, since evidence-based guidelines for diagnosing and treating DRPD, such as PTSD, serve as valuable tools for psychiatrists and other healthcare professionals, facilitating the formulation of tailored treatment plans for their patients (56).

Conclusions
The study revealed that over 90% of participants exhibited intent to treat, follow-up, or be involved in the management of DRPD, while nearly 80% possessed prior experience in treating these disorders.Findings suggest that within post-graduate medical education, Taiwanese psychiatrists demonstrate significant experience, willingness, and capacity to effectively manage DRPD.However, there is a need to integrate comprehensive training on disaster psychiatry into post-graduate psychiatric education programs to further enhance preparedness and optimize outcomes in managing these challenging conditions.

TABLE 2
Psychiatrists' previous experiences in the participations in the relief of disaster-related psychiatric disorders (n=103).

TABLE 3
Subjective feelings of competence in the management of disaster-related psychiatric disorders by psychotherapy (n=103).

TABLE 4
Medications and antidepressants chosen by psychiatrists for PTSD (n=103).

TABLE 5
Medications chosen by psychiatrists for disaster-related psychiatric disorders (n=103).

TABLE 6
Factors related to the experiences in dealing with disaster-related psychiatric disorders and the places of mobilization for interventions by multiple linear regression analysis (n=98).