Information was collected quickly over a period of 4 weeks in which there was much uncertainty about the nature of the disease being observed. The virtue of rapid communication of our experience is accompanied by the expectation that further experience over the coming weeks will bring greater clarity about the phenomena reported here. Furthermore, the observations were made in one large teaching hospital and may not be generalizable to other settings. An outbreak in a smaller community, for example, would probably present different challenges. In intervening with staff and patients, we found the stress-adaptation model particularly relevant. According to this model,12,13 the experience of stress is taken to be understandable as a universally experienced response to extraordinary life circumstances. Stressors must be identified, articulated and normalized as much as possible. The range of normal reactions, including anxiety and preoccupation, is not viewed as pathological but is, rather, encompassed, supported and realigned where appropriate, in order to facilitate adaptation. In our experience, support services for staff needed to be flexible, collegial and unintrusive. The presence of psychiatrists at nursing stations and at staff meetings helped to foster communication. Just the knowledge that support is available may suffice for many resilient staff members. There is an opportunity for leadership by example, when leaders advocate and use peer support. In this outbreak, the Department of Psychiatry was inMaunder et al 1250 JAMC • 13 MAI 2003; 168 (10) included in the command team not by design but by circumstance, because the Chair of the Medical Advisory Committee was the Chief of Psychiatry. Our experience suggests that psychiatry may have a special role to play in supporting institutional leadership during an outbreak, especially through the assessment of special staff and patient needs and the organization of a supportive institutional response. At our centre, strong pre-existing relationships among psychiatrists, administrators, nurses and social workers were very helpful in crafting flexible and responsive solutions to changing demands and stresses on staff, patients and families. Our experience in the early days of this outbreak taught us the paramount importance of a few frequently recurrent clinical themes. First, restorative sleep may be the first casualty of such an outbreak for all concerned and merits aggressive attempts to educate staff and patients about the impairment that results from sleep deprivation and to treat insomnia. Second, most people cope very well in their own way and benefit a great deal from a relatively small quotient of shared concern, good information and support. Third, when facing such a crisis it is crucial to feel that one is not alone. All efforts to overcome interpersonal isolation, from sharing jokes on the nursing station to conference calls, serve an important role in times of intense strain and stress. References 1. Health Canada. Summary of severe acute respiratory syndrome (SARS) cases: Canada and international [Web page]. Ottawa: Health Canada; 2003. Available: www.hc-sc.gc.ca/pphb-dgspsp/sars-sras/eu-ae/index.html (accessed 2003 Apr 14). 2. Centers for Disease Control and Prevention. SARS coronavirus sequencing. Available: www.cdc.gov/ncidod/sars (accessed 2003 Apr 14). 3. Poutanen SM, Low DE, Henry B, Finkelstein S, Rose D, Green K, et al. Identification of severe acute respiratory syndrome in Canada. N Engl J Med 2003 [republication ahead of print]. 4. World Health Organization. Severe acute respiratory syndrome (SARS). Wkly Epidemiol Rec 2003;78:81-3. 5. Perrett K, al-Wali W, Read C, Redgrave P, Trend U. Outbreak of meningococcal disease in Rotherham illustrates the value of coordination, communication, and collaboration in management. Commun Dis Public Health 2003;3(3): 168-71. 6. Mitchell A, Cummins T, Spearing N, Adams J, Gilroy L. Nurses’ experience with vancomycin-resistant enterococci (VRE). J Clin Nurs 2002;11(1):126-33. 7. Hrudey SE, Payment P, Huck PM, Gilham RW, Hrudey EJ. A fatal waterborne disease epidemic in Walkerton, Ontario: comparison with other