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Disaster Mental Health
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Resources
Disaster Mental Health Grand Rounds Presentation
New!
by Richard Weisler, M.D., David Post, M.D. and Allan Chrisman, M.D.
Lessons Learned From 9/11 and Hurricanes Katrina, Rita and Floyd
Disaster Mental
Health Web and Reference Guide
I. 1. Introduction:
The authors, Richard Weisler, M.D. (Duke
University Medical Center and UNC Chapel Hill Departments of
Psychiatry), Jonathan Davidson, M.D. and Allan Chrisman, M.D. (Duke
University Medical Center Department of Psychiatry), and Edna Foa, Ph.D.
(University of Pennsylvania Department of Psychiatry) have sought
to organize a practical, concise, up-to-date, and referenced mental
health guide which would be a useful resource for both primary care and
mental health providers after any type of natural or man-made
disaster. In this site we have included links to some key resources
on how to diagnose and deal with post-traumatic stress disorder and
other anxiety disorders, stress associated with relocation, bipolar
disorder, depression, as well as suicide prevention. Links are also
provided for other psychiatric consequences, including substance
abuse, which frequently follow natural disasters and terrorist
attacks. We also introduce links to psychotherapy approaches and
pharmachotherapy treatment options, which can be effectively used by
primary care and mental health providers.
Even in the best of
circumstances, most individuals with psychiatric problems are seldom
properly diagnosed and treated. Therefore, it is our hope that health
care providers who review information in these links and our planned
disaster mental health guide (being submitted for review) may improve
their routine care of patients.
In the spring of 2005, Drs.
Weisler and Davidson had, as volunteers,
assisted Pamela Tucker, M.D.
of the Agency of Toxic Substances and Disease Registry in the editing of
her section of a web based training course for first responders to
disasters located at http://www.phppo.cdc.gov/phtn/webcast/stress-05/ . Then
Drs. Foa and Chrisman joined the authors as volunteers in assisting Dr.
Tucker on a Relocation Stress Guide for those impacted by disasters, now
available at
http://www.atsdr.cdc.gov/publications/100233-RelocationStress.pdf.
After the severe damage inflicted by the recent hurricanes including
Katrina and Rita among others, all of the authors immediately
realized that the frequency of significant and often debilitating mental
health problems would most likely eventually equal, or surpass, the
disaster related morbidity and mortality associated with physical
problems. Collectively we began to work on developing an article that
could be a brief to guide mental health treatment following disasters.
The Centers for Disease
Control and Prevention (CDC) Needs Assessment Survey conducted in New
Orleans for the Louisiana Governor's Office in late October 2005
supports that view that disasters can significantly impact mental health
of an area. A staggering 48.1 % of the population the CDC surveyed in
Orleans Parish acknowledged a significant degree of mental distress on
the Individual Assessment of Mental Health Symptoms (SPRINT E)
instrument, and 70% of those impacted would be anticipated to accept a
mental health referral if offered. At the time of that CDC survey, only
1.6 % of the Orleans Parish was actually receiving mental health
services. The Substance Abuse and Mental Health Services
Administration has estimated 500,000 people have significant mental
health problems in the wake of Hurricanes Katrina and Rita. The mental
health infrastructure in the effected Gulf areas was often stretched in
the areas impacted by the hurricanes even prior to their hitting,
and mental health response capability has been further reduced since
Hurricanes Katrina and Rita.
We know that, untreated,
depression significantly increases the risks of heart attacks and
strokes while shortening survival rates after heart attacks. Yet,
mental health needs are often neglected by society. Major depression
decreases immune response and thus increases the risks of
infections, and it also increases the risks of diabetes, migraines, and
osteoporosis. Importantly, health providers need to be aware of the
dramatically increased risks of suicide, which may run about 15 times
higher for severely depressed people than in non-affected individuals. For
example, a bipolar patient who experiences an additional post-disaster
induced mood episode is at greater risk for suicide since he/she already
has a lifetime risk of suicide that far exceeds that of the general
population. The risk of suicide in
depressed/anxious patients is also much greater if individuals happen to
have a history of a past suicide attempt. Disaster
impacted residents may also have lost their housing, support system
and/or employment, or may abuse substances to try to cope; all of these
factors can also increase suicide risk. Decreased work
productivity, relationship problems, diminished quality of life, and the
decreased psychological resiliency frequently seen in patients with
mood, anxiety, and psychotic disorders all extract a heavy toll on
psychiatric patients and their families. Many individuals with untreated
mental illness will ultimately elect to self medicate with illicit drugs
or alcohol, creating a whole host of other problems for society and
themselves. Children and adolescents often struggle after disasters as
their whole world may be uprooted, with their parents, teachers, and
friends often struggling themselves just to cope.
It is our desire to help
physicians, Emergency Medical Responders, and other health providers
obtain information resources more easily in order to facilitate and
improve their evaluation and treatment of the many post-disaster mental
illnesses their patients may experience. It also is important for health
providers and Emergency Medical Responders to be able to recognize
possible psychiatric symptoms and problems, which may affect them
personally following disasters. If health providers can recognize their
own symptoms and problems, we hope that they will consider reaching out
to each other for support, briefly taking a step back to
decompress, and, if needed, seek evaluation and possible treatment.
Ultimately, if the web site and planned fact sheet guide raise awareness
of mental illness and treatment options facing medical responders and
their patients, then we will have done our job. The medical profession
and society can ill afford to fail to reach out to disaster impacted
residents and those responders who may have serious, yet very
treatable, mental disorders.
2 Why the need
for this website?
Given the scope and magnitude of recent
natural and terrorism related disasters, many authorities are
recognizing 1) a need for greater awareness of how to recognize and
treat the psychological sequelae of disasters for mental health
professionals and other health providers, 2) many disaster survivors are
seen in primary care settings and 3) a need for greater and closer
collaboration between mental health professionals and primary care
health providers in order to provide optimal care to both the medical
and psychological conditions that can occur during and after disasters.
II. General
Resources for Disaster Mental Health for Psychiatrists/Psychologists
1. What is Disaster
Psychiatry?
American Psychiatric Association
Disaster Response Section
http://www.psych.org/disasterpsych/katrina/resourcecenter.cfm
2. Specific
Resources for Psychiatrists and Psychologists Interested in Disaster
Mental Health
The following links
contain valuable online information for mental health professionals
interested in learning more about disaster mental health services and
the role of mental health professionals during disasters.
CDC Disaster Mental
Health Information for Professionals
http://www.bt.cdc.gov/mentalhealth/
Coping and Mental Health
After Disasters at the Center for Trauma Studies at Uniformed Services
University of Health Sciences (USUHS)
http://www.usuhs.mil/cbw/mental_health.htm
World Health Organization site on mental
health
http://www.who.int/mental_health/en/
National Center
for PTSD, Disaster Mental Health Services: A Guidebook for Clinicians
and Administrators
http://www.ncptsd.va.gov/publications/disaster/index.html
Guidelines for Mental Health Professionals'
Response to the Recent Tragic Events in the US
http://www.ncptsd.va.gov/facts/disasters/fs_guidelines_disaster.html
The lead
organizing component for the APA’s response to hurricanes is its
Committee on Psychiatric Dimensions of Disasters (CPDD). Visit the
CPDD’s web site at
www.psych.org/disasterpsych to obtain
information and handouts related to disaster psychiatry.
Notes
From the Oklahoma City's Recovery, A (APA) District Branch Perspective
http://www.psych.org/psych_pract/recovery.cfm
3. Resources on
specific DSM-IV disorders associated with
disasters
Acute Stress Disorder and
PTSD
References
for detection and treatment of acute stress disorder and PTSD include:
Davidson, JRT.
Recognition and Treatment of Post-Traumatic Stress Disorder. August 1,
2001. JAMA 286(5): 584-588.
Davidson JRT, Bernik M,
Connor KM, Friedman MJ, Jobson KO, Kim Y et al. A new treatment
algorithm for Post-traumatic stress disorder. Psychiatric Annals,
November 2005, 35(11): 887-900.
The American Psychiatric
Association and the U.S. Department of Veterans Affairs Office of
Quality and Performance have published practice guidelines for the
treatment and management of acute stress disorder. These can be found
at:
http://www.psych.org/psych_pract/treatg/pg/PTSD-PG-PartsA-B-C- New.pdf
Foa EB,
Keane T, Friedman M. Effective treatments for PTSD: Practice
Guidelines from the International Society for Traumatic Stress Studies,
New York, NY: The Guilford Press, 2000. and additional resources are
available at
http://www.med.upenn.edu/ctsa/ctsa_research.html
International
Post-traumatic Stress Disorder (PTSD) algorithm – website contains user
friendly, PTSD psychopharmacology treatment algorithms.
www.ipap.org/ptsd
Major Depressive
Disorder
For guidance in the
treatment of uncomplicated major depression, refer to American
Psychiatric Association Practice Guidelines for the treatment of
psychiatric disorders. Compendium 2004 or
Fochtmann, LJ and
Gelenberg, AJ. Guideline watch: Practice Guideline for the Treatment of
Patients with Major Depressive Disorder, 2nd edition. Focus:
The Journal of Lifelong Learning in Psychiatry, Winter 2005, III (1):
34- 42. at
http://www.psych.org/psych_pract/treatg/pg/MDD_Watch_031005.pdf
III.
Information on Disaster Psychiatry for Primary Care Physicians and
Mental Health Providers
Information resources for
the primary care physician on the recognition, diagnosis, and referral
for psychiatric as well as stress-related exacerbations of chronic
medical conditions encountered in disaster survivors who present in
primary care settings.
1. Help for the
Distressed Patient
Many patients may exhibit signs of
emotional distress because of fear, grief, and anger in the days, weeks,
and months after a disaster. These normal emotions will fade with time
but there is advice on how to conduct brief, supportive counseling that
the health care professional can give to help ease a patient’s distress.
Coping With a
Traumatic Event – For Health Professionals
How to help patients cope with a traumatic event
http://www.bt.cdc.gov/masstrauma/copingpro.asp
Coming ToTerms With
Grief and Loss at
http://www.postgradmed.com/issues/2000/11_00/zerbe.htm
Assessing Anxiety and
Depression in Primary Care also contains a section on when to make a
mental health referral at
http://www.mja.com.au/public/mentalhealth/articles/ellen/ellen.html
Why Refer to
Psychiatrist’s addresses hospital based referral issues for medical
patients at
http://www.rcplondon.ac.uk/pubs/ClinicalMedicine/0302_march_ed2.htm
2.
Help for the Overwhelmed or Suicidal patient
Some
patients may be so temporarily overwhelmed by their disaster-related
experiences that they may require more help than a simple counseling
session with their physicians. These patients may exhibit significant
emotional distress and inability to temporarily function. In this case,
referral to a mental health practitioner for crisis intervention may be
warranted.
Suicide Prevention
Crisis Hotline that is also available to assist people impacted
emotionally by Hurricane Katrina
By dialing
1-800-273-TALK (1-800-273-8255), callers are connected to a network of
local crisis centers across the country. Callers to the hotline
will receive counseling from trained staff at the closest certified
crisis center in the network.
The network is run by
Health and Human Service’s Substance Abuse and Mental Health Services
Administration and involves more than 110 certified crisis centers.
People who are in emotional distress or are suicidal can call at any
time from anywhere in the nation to talked to a trained worker who will
listen to and assist callers in getting the mental health help they
need. People in need will receive immediate access to local resources,
referrals, and expertise.
CDC suicide prevention information
http://www.cdc.gov/ncipc/factsheets/suicide-prevention.htm
Suicide Prevention in
Primary Care at
http://www.postgradmed.com/issues/2000/11_00/hamilton.htm
Hurricane Floyd 1999 - increased nonfatal
suicidal behavior http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4917a3.htm
Reporting on Suicide:
Recommendations for the Media
www.afsp.org/education/newrecommendations.htm
3.
Resources for helping patients with
disaster-related mental health sequelae
New onset DSM-IV disorders associated with
experiencing disasters include: major depressive disorder, generalized
anxiety disorder, acute stress disorder and post-traumatic stress
disorder, relapses or new onset of substance abuse. There may also be
exacerbations of pre-existing mental illnesses secondary to
disaster-related stress or loss of usual sources of care.
A. For reference books on psychiatric topics
for primary care physicians, see:
Massacheutts General Hospital Guide to
Primary Care Psychiatry, second edition. Stern, T.A., Herman, J.B., and
Slavin, P.L., editors. United States of America: McGraw-Hill Medical
Publishing Division, 2004.
Diagnostic and Statistical Manual of Mental
Disorders (4th edition, Primary Care Version). (1995)
Washington, D.C.: American Psychiatric Press.
4. Screening instruments and Brief
Diagnostic interviews –
For a short screen for the presence of
severe psychiatric illnesses that can be included in a routine history.
Initial primary care screening for severe
psychiatric illness from the Center for the Study of Traumatic Stress at
the Uniformed Services University at
www.usuhs.mil/csts/
at
www.usuhs.mil/csts/
Some office-based screens for common DSM-IV disorders -
PRIME-MD- A screening instrument designed for
used with general patients in a primary care setting. It can screen for
major depression, anxiety disorders, and somatization. A reference for
information about this instrument is: Robert L. Spitzer, MD; Kurt
Kroenke, MD; Janet B. W. Williams, DSW; and the Patient Health
Questionnaire Primary Care Study Group. Validation and Utility of a
Self-report verision of PRIME-MD The PHQ Primary Care Study. JAMA. 1999;282:1737-1744.
http://jama.ama-assn.org/cgi/content/abstract/282/18/1737
Beck Depression Inventory
– 21 item office-based self-rating scale for major depressive disorder
CAGE and RAPS questionnaires
– brief screening questions for problem
drinking in the primary care setting at
http://pubs.niaaa.nih.gov/publications/arh21-4/348.pdf
SPRINT –
brief 8-item assessment tool for PTSD. A reference about this
instrument is: Connor KM, Davidson JR. SPRINT: a brief global
assessment of post-traumatic stress disorder. Int Clin
Psychopharmacology. 2001. Sep 16 (5): 279-284.
Affective Disorder Evaluation Form
– a one-page patient self report form as well
as a 14 page clinical interview form.
Patient form-
http://manicdepressive.org/images/selfreport.pdf
Clinician interview
http://manicdepressive.org/images/blankade.pdf
For a brief structured
fifteen minute diagnostic psychiatric interview, the M.I.N.I. is an
often used resource. This also exists as a self-rating.
The reference for the
M.I.N.I. is: Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J,
Weiller E, Hergueta T, Baker R, Dunbar GC. The Mini-International
Neuropsychiatric Interview (M.I.N.I.): the development and validation of
a structured psychiatric interview for DSM-IV and ICD-10. J Clin
Psychiatry. 1998; 59 Suppl 20: 22-33.
For permission to use
the MINI, contact:
Mr. Christopher R. Gray,
President Medical Outcome Systems, Inc. at
cgray@medical-outcomes.com
Information is on
conducting a brief, office-based suicide risk assessment. The reference
for this assessment tool is: Shea SC. The chronological assessment of
suicide events: a practical interviewing strategy for the elicitation of
suicidal ideation. Journal of Clinical Psychiatry 1998; 59 Suppl 20:
58-72.
Suicidal
Ideation and Risk Levels Among Primary Care Patients With Uncomplicated
Depression
http://www.annfammed.org/cgi/content/full/3/6/523
5. Practice and
Referral Guidelines for specific DSM-IV disorders for primary care
physicians-
Acute Stress Disorder and
Post-traumatic Stress Disorder
VA/DOD Clinical Practice
Guideline for the Management of Post-Traumatic Stress Disorder.
Washington, DC: Department of Veterans Affairs/Department of Defense
Clinical Practice Guideline Working Group. December 2003. Office of
Quality and Performance publication 10Q-CPG/PTSD-04.
http://www.oqp.med.va.gov/cpg/PTSD/PTSD_cpg/frameset.htm
Post-traumatic Stress
Disorder: The management of PTSD in Adults and Children in
Primary and Secondary Care. London, England: Gaskell: 2005.
National Institute of Clinical Excellence Clinical Guideline 26.
http://www.nice.org.uk/pdf/Cgo26fullguideline.pdf
Massachusetts General Academy at
www.MGHCME.com
Module 2. Anxiety.
Pre-recorded educational symposium-available to physicians via web casts
or CD-ROM. The site contains lectures on Post-traumatic stress,
psychosocial strategies for treating anxiety disorders, and managing
anxiety disorders in primary care and general medical setting.
Referral Guidelines
Concise Guide to
Psychiatry for Primary Care Practitioners is a book that includes a
section on referral guidelines.
http://www.appi.org/book.cfm?id=8345
IV. Stress Management
Information for Disaster Responders and Physicians Involved in Disaster
Relief
Surviving Stress for First Responders –
Website providing a
segmented web cast with tips on stress management from the perspective
of different types of first responders, as well as a resource manual
with more information on stress management during disasters
http://www.phppo.cdc.gov/phtn/webcast/stress-05/
Stress Management for Health Care Providers-
Fact sheet providing
practical stress management advice for health care providers doing
disaster relief work
http://www.usuhs.mil/psy/StressManagement-HealthCareProviders.pdf
Listing of Impaired Physician State Program links
http://www.ama-assn.org/ama/pub/category/5705.html
V . Caring for
Psychological Issues of Children Affected by Disasters
Natural disasters are developmental crises
for children and adolescents. Reactions to a disaster depend on
cognitive, physical, educational, and social developmental level and
experience. The reactions of parents and adults around them also
strongly influence their perceptions and response. Maintaining contact
with the family, getting emotional support, adequate safety, and basic
needs met for food and shelter and a routine which promotes active
coping (developmentally appropriate constructive activities) most will
be resilient and have healthy outcomes. Such an experience can stimulate
learning and growth. The reactions of children and adolescents to the
trauma and resultant adjustment period usually last 1 to 2 months after
a disaster.
The loss of family/loved ones through separation
or death will superimpose a traumatic grief response, which requires
specialized treatment. Personal injury and associated medical
complications will also create traumatic reactions which are likely to
require specialized mental health treatment with cognitive behavioral
therapy customized to address the details of the events and experiences
of the child/adolescent.
Preventive intervention efforts to promote a
healthy coping that includes the acknowledgement of the events and
promotion of a positive outlook towards the recovery and future
reconstruction of community and personal/family lives have been proved
to be effective. The importance of friendships and peer relations should
be stressed along with good communication within the family. The use of
journaling and a scrap book approach have been developed as an ongoing
exercise over time with all family members, and/or in school classrooms
with teachers and peers or other community groups (My Katrina and Rita
Story, A Guided Activity Workbook for Children and Adolescents –
www.cphc-sf.org, An Activity Book for African American Families-http://www.nichd.nih.gov/publications/pubs/hccc/helping_children.htm
Children and adolescents emotional responses vary
according to their developmental level. Gender differences are also
noted with boys tending to have more behavioral symptoms and require a
longer period of recovery while girls tend to have more internalizing
emotional symptoms of anxiety and depression as well as more frequent
thoughts about the disaster.
Preschool and young school aged children may have
trouble verbally expressing these feelings and instead may express them
as a loss of developmental skills such as speech, toileting, being able
to go to sleep on their own and tolerate being separate from their
parents. Their play often reflects themes of the disaster (traumatic
play—a repetitive and less imaginative form of play that may represent
children’s continued focus on the traumatic event or an attempt to
change a negative outcome of a traumatic event).
School aged children may become preoccupied with
their own actions during the disaster and have continued concerns for
their safety and others safety. They may repetitively retell the story
about the disaster and express feelings of guilt, shame, helplessness or
sadness. However, fear was the most common primary reaction to the
events of September 11th among school-aged children. Interference with
their concentration and learning in school is common. Sleep disturbances
with nightmares, physical complaints of stomachaches or headaches, or
reckless impulsive/aggressive behaviors may also occur.
Adolescent psychological response to disaster most
closely resembles that of adults; symptoms of depression and anxiety
predominate. On the other hand, adolescents are more self conscious
about their emotional reactions especially feelings of shame, guilt,
fear and vulnerability. Because Katrina and Rita resulted in a loss of
lifestyle and loved ones through separation or death it is likely that
somatization, withdrawal, apathy, and depression will occur.
Additionally media accounts indicate that risk-taking behaviors such as
fighting and drug abuse are occurring as mechanisms of coping with
traumatic stress. Suicidal thoughts and actions are also a concern.
These reactions will interfere with identity development in adolescence
and can lead to enduring significant behavioral and emotional problems.
During a visit to the pediatrician or family
physician there is an opportunity to provide support to parents,
families and individual children and adolescents. Being able to identify
current signs and symptoms of stress reactions and lingering symptoms of
dissociation, depressive withdrawal or hyper-arousal helps determine the
need for a mental health referral. Tools currently available for this
assessment such as Hurricane Assessment and
Referral Tool for Children and Adolescents (www.nctsnet.org)
are very useful.
Specific enquiry about the events of the disaster
will also help identify individuals at high risk for long term
consequences i.e. loss of a parent, family member or friend, urgency of
evacuation; witnessing destruction of their home, school, loss of pets
and possessions, and families under financial distress.
The primary care physician should be aware when
making mental health referrals that not all interventions are created
equal: cognitive-behavioral therapy (CBT) has the strongest empirical
support for helping children. If children are suicidal, experiencing
ongoing stress in their environment, or are actively grieving the loss
of a loved one, they may need a combination of interventions in addition
to CBT. Some interventions can be harmful: psychological debriefing may
have negative effects and should not be used with children. Web based
training for trauma-focused CBT is available at the Medical University
of South Carolina in partnership with the National Child Traumatic
Stress Network
http://tfcbt.musc.edu/.
American Academy for Child and Adolescent
Psychiatry- contains referral sources for physicians.
http://www.aacap.org/
National Child Traumatic Stress Network -
contains a section for professionals with a schedule for training in
trauma and children, Providers’ Guide: Helping Children in the Wake of
Disaster, Hurricane Assessment and Referral
Tool for Children and Adolescents
www.nctsnet.org
American Academy of Pediatrics- contains
guidelines
How Pediatricians Can Respond to the Psychosocial
Implications of Disasters.
http://www.aap.org
VI. Substance Use Disorder Recognition and Treatment
Criteria for Substance Dependence Diagnosis
Website providing diagnostic criteria
http://www.nida.nih.gov/Drugpages/DSR.html
Helping Patients Who Drink Too Much A Clinician’s Guide.
http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm
The National Institute of Drug Abuse (NIDA) Clinical Toolbox:
Science- Based Materials for Drug Abuse Treatment Providers.
http://www.nida.nih.gov/TB/Clinical/ClinicalToolbox.html
VII. Links to Resources for Disaster and General Mental
Health for the Public, but also useful for health providers
Relocation Stress Helping
Families Deal with the Stress of Relocation After a Disaster at
http://www.atsdr.cdc.gov/publications/100233-RelocationStress.pdf
American Psychological
Association Consumer Help site
http://www.apahelpcenter.org/
National Mental Health
Information Center, Substance Abuse and Mental Health Services
Administration (SAMHSA)
Contains information for
adults, children, and first responders
http://www.mentalhealth.samhsa.gov/
Depression Bipolar
Support Alliance site contains information on mental disorders written
for families and patients. Self-screening scales are available to help
people recognize depression, bipolar, and anxiety disorders. Patient
specific information on suicide prevention and treatment options is also
available.
http://www.dbsalliance.org
Anxiety Disorders
Association of America site contains useful information of all types of
anxiety disorders and a link to help finding therapists at
http://www.adaa.org/
National Alliance for
the Mentally Ill is a useful source of information on most mental
disorders
http://www.nami.org/
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Helping Families Deal With the Stress
of Relocation After a Disaster
·
Resources
·
Stress Overview
·
Contact Information
Stress Overview?
What is included in this handout
This handout gives you information and tips that explain
• basic information about stress,
• signs of and ways to help family members deal with relocation stress,
• signs of stress in young people of different age groups (preschool to
high school age),
• ways to help young people deal with stress (preschool to high school
age),
• how to help the elderly deal with relocation stress, and
• where to find further information on these topics.
http://dukehealth.org/disaster_mental_health
Contact
Info
Disaster Mental Health
Director, Richard Weisler, M.D.
Duke University Medical Center
Durham, NC 27705
Email: rweisler@aol.com
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