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This study presents information on the design and creation of a standard operation procedure
(SOP) for psychiatric service after an earthquake. The strategies employed focused on the
detection of survivors who developed persistent psychiatric illness, particularly post-traumatic stress
and major depressive disorders. In addition, the study attempted to detect the risk factors for
psychiatric illness. A Disaster-Related Psychological Screening Test (DRPST) was designed
by five psychiatrists and two public health professionals for rapidly and simply interviewing
4,223 respondents within six months of the September 1999 Chi-Chi earthquake. A SOP was
established through a systemic literature review, action research, and two years of data collection.
Despite the limited time and resources inherent to a disaster situation, it is necessary to develop
an SOP for psychiatric service after an earthquake in order to assist the high number of survivors
suffering from subsequent psychiatric impairment.
Introduction
The devastating Chi-Chi earthquake, with its epicentre near the Chi-Chi Township
of Nantou County, Taiwan, measured 7.3 on the Richter scale and struck in the early
morning of 21 September 1999 (9/21) (Chou et al., 2007). Earthquakes were re
sponsible for several devastating natural disasters in the twentieth and twenty-first
centuries (Chou et al., 2003). In 2004, a catastrophic earthquake (9.0 on the Richter
scale) in the Indian Ocean triggered a tsunami that resulted in the deaths of hun
dreds of thousands of people in South and Southeast Asia (van Griensven et al.,
2006; Chou et al., 2007). In 2008, an earthquake in Szechwan, China, highlighted
the importance of disaster psychiatry.
In comparison to hurricanes and floods, the occurrence of an earthquake is harder
to predict. Furthermore, aftershocks often cause survivors to re-experience the
traumatic event. In addition, earthquakes frequently cause more deaths and severe
injuries than other types of natural disaster (PAHO, 1981), and more time is re
quired for the rescue of survivors of earthquakes and for the reconstruction of their
lives (Alexander, 1991). The damage caused by an earthquake can be extensive and
severe, and its effects often persist long after the event (Chou et al., 2004a, 2007).
Following the 1999 Chi-Chi earthquake, the research team planned psychologi
cal rehabilitation programmes for Yu-Chi Township. Yu-Chi was near the epicentre
Disasters, 2011, 35(3): 587−605. © 2011 The Author(s). Disasters © Overseas Development Institute, 2011
Published by Blackwell Publishing, 9600 Garsington Road, Oxford, OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA
588 Chao-yueh Su et al.
of the earthquake, providing the team with an opportunity to study the impact of
a natural disaster on survivors, both in general and with a focus on the Taiwanese
population (Chou et al., 2005).
The human impact of a mass disaster is a composite of two elements: the cata
strophic event itself; and the vulnerability of those people affected by the event
(Sapir, 1993). Studies focused on the survivors of the Chi-Chi earthquake found evi
dence of psychological sequelae, including post-traumatic stress disorder (PTSD),
major depressive disorder, sleep disorder, anxiety, and substance abuse (Chen et al.,
2001; Chang et al, 2002; Hsu et al, 2002; Kuo et al, 2003; Yang et al, 2003; Chou
et al., 2004a, 2004b, 2005, 2007; Lai et al, 2004; Liu et al., 2006; Wu et al, 2006;
Tsai et al., 2007). The quality of life of survivors who develop psychiatric illnesses
or impairments is poorer than it is among those without a psychiatric illness (Chou
et al., 2004b; Wu et al, 2006; Tsai et al., 2007). In addition, rescue workers (such
as fire-fighters, nurses and soldiers) may develop physical or mental impairments
(Liao et al., 2002; Shih et al., 2002; Yeh et al., 2002; Chang et al., 2008).
The researchers used PubMed (http://www.ncbi.nlm.nih.gov/pubmed) to search
for Chi-Chi earthquake-related papers published between January 2001 and June
2009. Table 1 summarises all of the Chi-Chi earthquake papers related to psychiatry.
It is difficult to reconstruct an individual’s life after a disaster. The Sphere Project2
and Inter-Agency Standing Committee have provided multi-sectoral guidelines to
mange such situations (IASC, 2007). Strong inter-relationships among social, mental
and physical aspects of health are commonly ignored in the rush to organise and
provide health care (IASC, 2007). This paper focuses primarily on mental reha
bilitation. Therefore, it attempts to offer an integrated step-by-step screening and
reconstruction procedure for psychiatric aspects of rehabilitation.
No extensive, systemic research programmes for post-disaster psychiatric services
existed in Taiwan or China prior to the Chi-Chi earthquake. While the authors
recognise the importance of mental health, understanding it is not the same as valu
ing it. There is a wide gap between knowledge and action. Rehabilitation efforts
should concentrate not only on severe mental illnesses (SMIs) but also on emotional
disturbances and personality traits or disorders. When facing stress, frustration or
traumatic events (such as risk factors or deprivation of internal or external resources),
individuals become vulnerable to psychiatric impairment and disease. Other fac
tors that tend to increase individuals’ vulnerability to psychiatric problems include
brain damage, heredity, personality traits, life events, and social interactions (Krause,
1987; Ursano, Kao and Fullerton, 1992). Consequently, multiple risk factors con
stitute a network that results in psychiatric illness. An individual might reach a
sub-threshold of psychiatric illness and then develop the illness due to the decreas
ing availability of resources, the accumulation of risk factors, or a major stressful
event. Furthermore, unresolved sub-clinical psychiatric symptoms caused by a dis
aster might increase survivors’ sensitivity to future stresses (Heim and Nemeroff,
2001). Post-disaster survivors need, therefore, specific, systemic evaluation and
management. Some studies have shown that trauma increases help-seeking, which
Table 1 Summary of Chi-Chi earthquake papers related to psychiatry (PubMed search, January 2001–June 2009)
Chen C.C. et al. 2001 Within 1 month 525 residents Screening for psychiatric morbidity Purposeful sampling 11% of the subjects reported having
and post-traumatic symptoms among thoughts of death or ideas of suicide.
survivors in the early stage 89.9% of respondents had psycho-
logical impairment.
Chen C.H. et al. 2001 Within 2 years 210 residents The Chinese version of the Davidson Translation, back-translation and Sensitivity of the instrument was 0.9,
Trauma Scale, a practice test for concurrent validity specificity was 0.81, positive likeli-
validation hood ratio was 4.74, and negative
likelihood ratio was 0.12.
Chang et al. 2002 6 months later 171 pregnant Psychiatric morbidity and pregnancy Purposeful sampling The prevalence of minor psychiatric
residents outcome in a disaster area. morbidity (MPM) was 29.2%.
Hsu et al. 2002 6 weeks later 323 student PTSD among adolescent earthquake Purposeful sampling Of 323 students, 21.7% had PTSD.
residents victims in Taiwan Being physically injured and experi-
encing the death of a close family
member with whom they had lived
were the two major risk factors.
Liao et al. 2002 2 months later 1,104 rescue Association of psychological distress Purposeful sampling Prevalence of general psychological
workers serv- with psychological factors in rescue distress is high among rescue work-
ing in the area workers ers. Personality traits and pre-disaster
hit by the life adjustment had a dominant
earthquake predictive power for psychological
distress.
Lin et al. 2002 1 year later 368 residents Geriatric survivors Purposeful sampling Lower quality of life in physical
(268 residents capacity, psychological well-being,
≥ 65 years old) and environment 12 months after
the earthquake when compared to
assessment prior to the earthquake.
The establishment of a standard operation procedure for psychiatric service after an earthquake
589
590
Shih et al. 2002 Within 1 year 46 nurses who The impact of the 9-21 earthquake Purposeful sampling The rescue experience helped to
worked in a experiences on Taiwanese nurses as strengthen most Taiwanese nurses’
hospital in the rescuers professional competency.
community
Yeh et al. 2002 Within 16 days 187 young, Characteristics of acute stress symp- Purposeful sampling Significant inverse correlation was
Chao-yueh Su et al.
male military toms and nitric oxide concentration observed between the severity of
personnel in young rescue workers in Taiwan stress symptoms and the plasma
who served concentration of nitric oxide in
as rescue rescue workers.
workers
Chang et al. 2003 5 months later 84 male Post-traumatic distress and coping Purposeful sampling 16.7% and 21.4% prevalence of
fire-fighters strategies among rescue workers general psychiatric morbidity and
post-traumatic morbidity.
Chou et al. 2003 21 months later 461 residents Establishment of a disaster-related Population survey The DRPST, which was administered
psychological screening test in phase 1 of this two-phase study,
may be used for effective and rapid
screening for PTSD and MDE after an
earthquake.
Kuo et al. 2003 2 months later 120 bereaved To investigate the prevalence of Purposeful sampling PTSD: 37%; major depressive disorder:
survivors psychiatric disorders and risk factors 16%.
for PTSD and major depressive disor-
der among bereaved survivors
Yang et al. 2003 3 months later 663 victims To investigate the psychiatric morbid- Purposeful sampling PTSD: 11.3%; partial PTSD: 32.0%.
ity and post-traumatic symptoms
among earthquake victims in primary
care clinics
Chou et al. 2004a 21–24 months 461 residents To investigate quality of life and Purposeful sampling The prevalence of varied psychiatric
related risk factors in Taiwanese disorders in earthquake survivors
earthquake survivors with different ranged from 3.3–18%.
psychiatric disorders
Chou et al. 2004b 4–6 months 4,223 To investigate the relationship Purposeful sampling PTSD: 7.6%; suspected PTSD: 26.7%.
residents between quality of life and Worse quality of life in psychiatric
psychiatric impairment impairment patients.
Guo et al. 2004 1 month 252 rescue To investigate the prevalence of Purposeful sampling The prevalence of PTSD among
workers PTSD among professional and non- professional and non-professional
professional rescue workers involved rescuers were 19.8% and 31.8%.
in the 1999 Chi-Chi earthquake Disaster rescue work is associated
with a high level of stress, even
among highly trained professionals.
This work may lead therefore to
mental health problems.
Lai et al. 2004 10 months 252 residents Full and partial PTSD among earth- Randomly selected from two rural The prevalence rates for PTSD (n = 26)
quake survivors in rural Taiwan communities and sub-threshold post-traumatic
stress syndrome (PTSS) (n = 48) were
10.3% and 19.0%, respectively.
Chou et al. 2005 4–6 months 442 residents To assess the development of psychi- Population survey Females had significantly higher
atric disorders among residents post rates of most psychiatric disorders in
earthquake comparison to males.
Yang et al. 2005 During a 7- year – To examine time trends of increased Time-series analysis The mean monthly suicide rate for
period suicide rates earthquake victims was higher,
indicating the need for strengthened
psychiatric services in the first year
after a major disaster.
Seplaki et al. 2006 Before and after the 1,160 older To investigate variability in resilience Longitudinal survey with interviews Persons of low socioeconomic status,
earthquake individuals to depressive symptoms in the socially isolated individuals, and
aftermath of the 1999 earthquake women reported higher levels of
depressive symptoms than their
respective counterparts, as did persons
who experienced damage to their
homes. The psychological effects of
damage were strongest among those
aged between 54 and 70 years.
Wu et al. 2006 33–36 months 405 residents To investigate quality of life and Population survey The prevalence range for psychiatric
related risk factors in earthquake disorders in the earthquake survivors
survivors diagnosed with different was 0.2–7.2%. The persistence of
psychiatric disorders long-term economic problems was
one of many important factors affect-
ing quality of life.
The establishment of a standard operation procedure for psychiatric service after an earthquake
591
592
Chen et al. 2007 2 years later 6,412 earth- To examine the prevalence and risk Purposeful sampling The estimated rates of PTSD caseness
quake survivors factors of post-traumatic stress and psychiatric morbidity were 20.9%
whose houses symptoms and psychiatric morbidity and 39.8%, respectively. Psychiatric
were destroyed morbidity occurred mainly in survi-
vors who were female, older, with a
Chao-yueh Su et al.
Chou et al. 2007 6 months, 2 years 442, 461 and To survey the dynamic population for Population survey PTSD decreased significantly three
and 3 years later— 405 residents the risk factors of PTSD and major years later. However, suicidal ten-
total three times depression, as well as the prevalence dency and drug abuse/ dependence
of different psychiatric disorders six increased significantly.
months, two years and three years
after the earthquake
Kuo et al. 2007 1 year later 272 victims To investigate the incidence of PTSD Purposeful sampling Post-traumatic symptoms and psy-
from temporary among and the psychological health chological problems were more
housing units status of earthquake victims one year prevalent among women (22.2% and
after the event 64%, respectively) than among men
(9.2% and 47.9%, respectively).
Tsai et al. 2007 3 years later 1,756 To evaluate prospectively the rela- Fixed cohort follow-up Three years after the earthquake, the
respondents tionship between the clinical course estimated rate of post-traumatic stress
of post-traumatic stress symptoms symptoms had declined, and the
and quality of life quality of life of the survivors varied
according to how their post-traumatic
stress symptoms had progressed.
Chang et al. 2008 – 193 fire- To investigate the modification effects Purposeful sampling Older age and longer job experiences
fighters of coping strategies on the relation- (more than three years) were associ-
ship between rescue effort and ated with both general psychiatric
psychiatric morbidity in earthquake and post-traumatic morbidities.
rescue workers
The establishment of a standard operation procedure for psychiatric service after an earthquake 593
suggests that active screening and long-term psychiatric services are helpful for
survivor populations. In addition, a 2008 report offered some recommendations for
improving the psychiatric services delivered in a tertiary hospital (Humayun, 2008).
Yet a systemic and effective method of offering psychiatric services post earthquake
was not established. Hence, the goal of the current project is to present information
on the design and creation of a SOP for psychiatric service after an earthquake.
Methods
1. Instrument
A) Disaster-Related Psychological Screening Test (DRPST)
Immediately following a disaster, it is important to evaluate the damage and to
administer properly designed questionnaires to screen for mental symptoms among the
survivors. Moreover, the identification of at-risk groups may be facilitated by simple
screening instruments designed to detect significant emotional stress (Somasundaram
and van de Put, 2006).
Five psychiatrists and two public health professionals designed the DRPST to
collect background information from residents and to determine their psychological
symptoms. Sleep disorders and anxiety disorders were included in the draft DRPST
until the researchers discovered that their psychiatric symptoms had a high preva
lence and were non-specific for further evaluation. Although the symptoms of these
two disorders had been screened, they were not good indicators of high-risk groups.
The high sensitivity and low specificity of the original DRPST resulted in a poor
positive predictive value (PPV). The main measure includes 17 PTSD items and
nine major depressive episode (MDE) items that were created based on DSM-IV-
defined3 disaster-related psychiatric disorders.
The questionnaires were designed to take account of the local language dialect
(Chou et al., 2003, 2004a).
Most of the earthquake survivors still suffered the impacts of the earthquake and
they may have lacked patience due to a stress-induced reaction. As a result, they may
have refused to be screened if there were too many items on the questionnaires.
It was necessary, though, for the psychiatric research team to identify quickly the
potential cases. Hence it reduced the number of items and retained the validity of
the questionnaires. Best subset regression analysis and the receiver operating char
acteristics curve were utilised to select a subset of items and cut-off points for the
DRPST (Chou et al., 2003). Thus, the DRPST (still based on DSM-IV symptoms)
includes a seven-symptom scale for selecting probable PTSD screening and a three-
symptom scale for selecting probable major depression screening. Scores of four or more
on the PTSD scale were used to define a group of survivors with probable PTSD,
and scores of two or more on the major depression scale were used to define a
group of survivors with probable major depression (Chou et al., 2003). Compared to
the Mini-International Neuropsychiatric Interview in a population similar to that
594 Chao-yueh Su et al.
used in the present study, sensitivity was 76.1 per cent, specificity was 99.8 per cent,
the PPV was 97.2 per cent, and the negative predictive value (NPV) was 97.4 per
cent for PTSD. For major depressive episode, sensitivity was 92.1 per cent, specifi
city was 98.3 per cent, the PPV was 83.3 per cent, and the NPV was 99.3 per cent
(Chou et al., 2003).
3. Procedures
This is an empirical and action study. A total of 4,223 respondents were screened
between one week and six months of the earthquake. The adjusted response rate
was 60.3 per cent in the first population survey conducted between four and six
months (0.5 years) after the earthquake (Chou et al., 2004a); 1,756 of these respond
ents were included in the follow-up conducted 33–36 months (three years) after the
earthquake (Tsai et al., 2007). Of the group of 2,467 (4,223 - 1,756) participants who
were not part of the follow-up, 1.4 per cent died, 6.1 per cent moved away, 55.4 per
cent lived outside of the township because of employment, 1.2 per cent lived out
side of the township for educational purposes, 30.4 per cent refused to participate in
The establishment of a standard operation procedure for psychiatric service after an earthquake 595
the study, and 5.5 per cent could not be found after three visits to their homes.
Since the catastrophic earthquake affected millions of people who lived near the
epicentre, there was insufficient psychiatric manpower to screen and manage all of
the victims. Regular psychiatric service was offered in a fixed place at the outset.
However, little service (only eight cases in two months) was provided due to passive
attitudes, a lack of knowledge of psychiatric illness, and social stigma. The service
model was changed to home-visit treatment (door-knocking) after discussion at a
meeting of experts. Even though this method was expensive in terms of human
resources, home-visit (door-knocking) treatments increased the reception of psy
chiatric treatment. Continuous home-visit treatment is the best way to ensure that
people with mental illness receive medication and treatment (Lin et al, 2004; Tsai
et al., 2004). A flexible, proactive, and assertive approach to service delivery during
the crisis situation helps to make certain that care needs are met (McMurray and
Steiner, 2000). Repeated discussions among team members and literature reviews
were encouraged. Before the home-visit interviews, assistants made telephone calls
to the respondents. Psychiatric health education was held during traditional festival
activities to establish a better rapport and to decrease the stigma associated with men
tal disorders. All of these efforts helped the psychiatric evaluations and treatment
programmes to proceed smoothly.
The team, responsible for Yu-Chi Township, located near the epicentre, thus
attempted to develop a rapid and valid tool and an SOP to identify the survivors
with psychiatric impairments or diseases. The clinical difficulties were discussed in
a meeting, and a proper management process was established within one year. The
team analysed the data and questions and then produced a draft SOP and clinical
guidelines based on expert consensus. When the provisions of these guidelines were
completed in 2005, scholars and professionals were invited to evaluate them. Finally,
two years later, the researchers revised the SOP, DRPST, and clinical guidelines.
Results
1. Demographic data and grouping
Of the 4,223 respondents, 1,448 (34.3 per cent) exhibited moderate-to-severe psychi
atric impairment. The respondents were stratified into four psychiatric impairment
groups, which were determined according to DRPST score: healthy (n = 952; 22.5
per cent); mild (n = 1,823; 43.2 per cent); moderate (n = 1,126; 26.7 per cent); and
severe (n = 322; 7.6 per cent). The proportion of male respondents was higher for
the healthy group (59.1 per cent) than for the psychiatrically impaired group (36.3–
50.2 per cent) (Chou et al., 2004a). The team followed up with 1,756 of the 4,223
respondents three years later. The average age of the 1,756 respondents was 54.5 ± 16.7
(range: 16–98); roughly 54.4 per cent of the respondents were women (male: 801;
female: 955). The education level was predominantly primary school or lower (64.5 per
cent). At six months and three years after the earthquake, the estimated rates of post-
traumatic stress symptoms were 23.8 and 4.4 per cent, respectively (Tsai et al., 2007).
596 Chao-yueh Su et al.
Figure 1 Cont.
and rescue-worker team) should be involved during the urgent initial stage. An
emergency management system should be established to intervene effectively imme
diately after a disaster. Systemic mental rehabilitation should be performed one to
three months after the disaster, as detailed in Figure 1.
Discussion
1. Early detection and intervention after the disaster
In general, an integrated rehabilitation programme is a balanced initiative with the pur
pose of helping all members of the community recover via different plans, activities
and resources. Essential community resources that are likely to be helpful in respond
ing to a disaster (such as schools, hospitals, places of worship, shelters, community
halls and local service groups) should be well-known (Somasundaram and van de
Put, 2006). These resources should be formulated and integrated to achieve maxi
mum effectiveness. If there are no special conditions, a localised rehabilitation pro
gramme should be considered during the recovery period. It is necessary to intervene
in a step-by-step manner and to manage subjects systematically (see Figure 1).
After the acute stage, some people can recover from anxiety and panic. However,
some people with different degrees of mental disorder require continuous psychi
atric intervention. The prevalence rates of mental disorder, especially PTSD and
major depressive disorder, increase in the first two years after an earthquake (Chou,
F.H.et al., 2003, 2004b). The prevalence rates of psychiatric illness decrease in the
third year after an earthquake, but the prevalence rates of suicidal tendency and
sedative dependence/abuse continue to rise (Chou, F.H. et al., 2003, 2004b; Wu et
al., 2006). For these reasons, the team continued home-visit treatment throughout
the first two years. In addition, it encouraged local mental health clinics to follow
up with high suicide risk respondents during the third year.
Rescue efforts should occur within 24 hours of a disaster. The first job is to save
the victims’ lives within the critical three-day period. The establishment of an emer
gency medical station to provide physical, psychiatric and public heath epidemic
intervention and services needs to be completed within one week. With regard to
the psychiatric aspect, one additional month is needed to screen for psychiatric
symptoms and illnesses, such as acute stress disorder. After three to six months,
chronic type and delayed onset PTSD should be detected (DSM-IV-TR). Given
that the team found that the prevalence of PTSD decreased after three years, this
study suggests that the total follow-up period last three years.
future and life-threatening situations also make immediate psychiatric services useless.
For example, some survivors with acute stress responses (such as insomnia, anxiety
or panic-like symptoms) refuse to take hypnotics or calmatives. These people fear
that they will be unable to escape another disaster if they take the medication (in
fact, some aftershocks of the Chi-Chi earthquake measured 6.8 on the Richter
scale). It seems as though some type of alternative therapy could be another method
of transient management in the chaotic stage immediately after the disaster. For
example, a rescue soldier complained about nightmares due to seeing and moving
a corpse. He thought that he could not fall asleep because of the ‘ghost’ around
him. He did not believe that any therapist or medication would help him, so a doc
tor gave him a bottle of mineral water imbued with magical effects from Buddha.
The soldier could fall asleep quite easily after the doctor’s employment of the placebo
effect (Chou, F.H. et al., 2003). This traditional help-seeking behaviour and the
resulting help strategy must be understood on a cultural basis. Accommodations
must be made since more conventional methods of mental health intervention may
not meet with the same acceptance in different cultures (Somasundaram and van
de Put, 2006).
Furthermore, holding religious rituals in the first three months after a disaster
can stabilise victims’ mental health. Such rituals provide another type of ‘group
therapy’. Except in the management of survivors with severe mental disorders, strict
use of traditional psychiatric medicine is unnecessary at this stage. Transient alter
native therapies may decrease the incidence of disturbance among the survivors.
Religion often supports the helpless, especially post-disaster. Alternative approaches
may include establishing support groups for specific survivors as well as more un
orthodox approaches, such as ‘inventing’ new rituals that help people deal with the
specific traumatic event(s) (van de Put and Eisenbruch, 2004). When a disaster occurs,
resources can be combined to assist the public and provide mental health education
activities, especially for those who resist psychiatric treatment.
This period of rescue and recovery was difficult for the research team, as there
was limited local experience and no clinical guidelines for dealing with such a
situation. Due to ethical concerns, a case control study design could not be used to
compare the efficacy of various procedures. Clinical services were offered before
the team began the study. Clinical experience provided the team with many valu
able observations. For example, repeated questionnaires performed by different
rescue teams made people resist and refuse further evaluation and referrals. Long-
term tracking of these people was hard because of the stigma of such variables as
psychiatric illness and moving away. In addition, it was hard to integrate all aspects
of the resources in a way that would allow them to be managed effectively.
Conclusion
There are still many undetected factors that must be overcome when facing new
challenges in the twenty-first century. Although the types of disasters may vary, it
is vital to train a sufficient number of specialists and to create an SOP for reducing
disturbing conditions when any disaster occurs. The research team humbly offers
its experience and psychiatric intervention model to those who need it, although it
hopes that there will be no catastrophic disasters in the future.
Acknowledgements
The authors thank the staff of the Kai-Suan psychiatric hospital, the teachers and
postgraduate students at the Institute of Public Health at the National Yang-Ming
University, and assistants Meng-Jun Pan, Shih-Pei Shen and Shih-Shih Chao. The
study was supported by grants from the National Science Council (NSC 92-2625-
Z-280-001 and NSC 93-2625-Z-010-001).
Correspondence
Wen-Kuo Lin, Department of Community Psychiatry, Kai-Suan Psychiatric Hospital
130, Kai-Suan 2nd Rd, Lingya district, Kaohsiung, Taiwan. Telephone: +886-7-7513171-
2232; fax: +886-7-5373299; e-mail: lwk1975@yahoo.com.tw
Endnotes
1
Chao-yueh Su, Med is Assistant Professor at the Department of Nursing, I-Shiou University,
Taiwan; Frank Huang-Chih Chou, MD, MS, PhD is Deputy Superintendent at the Department
of Community Psychiatry, Kai-Suan Psychiatric Hospital, and Adjunct Associate Professor at the
Department of Nursing, Meiho University, Taiwan; Kuan-Yi Tsai, MD, MS is Attending Physician
at the Department of Community Psychiatry, Kai-Suan Psychiatric Hospital, Taiwan; and Wen-Kuo
Lin, MD is Attending Physician at the Department of Community Psychiatry, Kai-Suan Psychiatric
Hospital, Taiwan.
The establishment of a standard operation procedure for psychiatric service after an earthquake 603
2
See http://www.sphereproject.org/.
3
See http://allpsych.com/disorders/dsm.html.
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