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Disaster Mental Health Basics

Grand Rounds 2013
by

Sander Koyfman

on 11 September 2013

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Transcript of Disaster Mental Health Basics

Disaster Mental Health Basics
Disaster Mental Health
What do you need to know?
What should you expect?
How can you prepare?
How can you help?

Priorities Facing an Individual Practitioner
Taking care of own family
Take care of professional obligations
Taking care of self

Taking Care of Others
Whom Do You Ask for Help?
A growing number of national and international organizations publish converging guidelines on disaster mental health today
Who May Ask for Your Help?
Disaster Psychiatry Outreach
American Red Cross
American Psychiatric Association
Medical Reserve Corps
NVOAD
Local Religious and Civic Organizations
Your own clinic, hospital, neighborhood
Dr. Sander Koyfman
Disaster Psychiatry Outreach
Kings County Hospital

Piotr Redlinski for The New York Times
Dr. Hirschowitz during his daily training routine in Central Park.
What Do You Need to Know?
American Psychiatric Association

APA Committee on Psychiatric Dimensions of Disaster

http://www.psychiatry.org/practice/professional-interests/disaster-psychiatry
Group for the Advancement of Psychiatry - http://ourgap.org - a national think tank

Disaster Psychiatry Outreach -
www.disasterpsych.org

October 6th, 213 - 5th International Congress on Disaster Psychiatry, NYC, Bellevue Hospital - registration is now open!
Psychological First Aid Field Operations Guide from the The National Child Traumatic Stress Network and the National Center for PTSD (now in Second Edition).

Psychological First Aid is an evidence-informed approach for assisting children, adolescents, adults, and families in the aftermath of disaster and terrorism.

The Psychological First Aid Field Manual - http://www.ptsd.va.gov/professional/manuals/psych-first-aid.asp
"Our goal is to provide information and resources to professionals, the general public, States, territories, and local entities for emergency preparedness and disaster response." - http://www.samhsa.gov/Disaster/
Trauma….

Stress…

disaster psychiatry outreach

Epidemiologic Data of Pre-hurricane residents in Gulf States 5-8 months and then another year post-Katrina showed clear increases:

PTSD
increases from 14.9% to 20.9%
Suicidal ideation 2.8% to 6.4%
Suicide plans 1.0% to 2.5%

Kessler et al., 2008
Hurricane Katrina

disaster psychiatry outreach
Basic Framework of
Understanding Disasters
Cycles of Disaster
dpo
disaster psychiatry outreach

Pre-disaster
Impact
Acute Phase
Post-acute phase
Baseline Functioning Community
Social Problems may exist
Prior Trauma may evidence self
24-48 hours post impact
Initial chaos with only primary safety needs at the forefront
High adrenaline, lack of clarity
Extends up to 2 months
Community takes stock and forms initial response
From 2 months and beyond
New post-trauma balance is established
An opportunity for growth
Stress: An occurrence which disturbs someone’s usual sense of equilibrium but for which they have the coping abilities to restore that equilibrium.
Trauma: A trauma is stress that overwhelms an individual’s capacity to respond and cope
Disaster: Trauma at the community level
Intense, transient, & fluid

Physical - Palpitations, shortness of breath, dizziness, sweating, loss of appetite, chest pain
Cognitive - Distractibility, confusion, watchfulness, questions of meaning, expectation of harm, nightmares
Emotional - Fear, anxiety, depression, irritability, fatigue/exhaustion
Behavioral - Insomnia, interpersonal conflict, agitation, social withdrawal, social dependency, loss of routine, substance use
Post-disaster problems are not the same as Post-Traumatic
Stress Disorder
1-800-LIFENET: a 24-hour/day hotline funded by the Department of Health and Mental Hygiene to provide mental health referrals appropriate to patient’s geography and ability to pay

311: A New York City hotline for all other inquiries, including social services

Local Mental Health Services

Social support - Developing and nurturing friendships; seeking resilient role models and learning from them
age and life experience can often serve a protective role
seek out those you trust and have relied upon in previous crisis to get the reliable and reassuring support.
Remember, you have been thru other stressful events in your life and you have come through and came out on the other side. You’ll come through again.

Resilience – Social Support

Active coping style - Problem-solving and managing emotions that accompany stress; learning to face fears – in other words – deal with problems as they come.
The significant majority of those effected will walk away with passing symptoms.
Identifying resources in the community is an important step to recovery
Resilience – Active Coping


Direct victims: 30-40%
Rescue workers: 10-20%
General population: 5-10%

Post Disaster PTSD Prevalence


Return to “everyday life”
Removed from immediate threat
Re-establish contacts, work, and homes

Post-Acute


Options for follow-up should be known prior to clinical intervention
Linkages with local services
Clinicians should not self-refer

Aftercare

Opportunities to share one’s story and experience may be helpful
Opportunities for psychoeducation and informal assessment
Avoid strict models
Never should be mandatory

but

Heterogeneous groups can expose members to new traumas
Debriefing during ongoing trauma can worsen the trauma exposure
Confusion of grieving individuals with traumatized individuals
One time intervention is highly desirable but elusive
Psychological Debriefing

Mental Health providers should not assume that all survivors will need psychotherapy
Appropriate needs assessment and triage should help identify those at most risk (proximity, direct injury, pre-existing diagnosis etc.)
Individual preference - should only be a guide, secondary traumatization must be avoided in group modalities
Psychotherapy
Empathic, supportive, and practical
Targeted mental health interventions addressing impairment, symptoms, acute issues, and referral
Focusing on
sustained
local resources even if "imperfect" far more important than "gold standard" that cannot possibly be maintained.
Interventions

Acute diagnoses

Anxiety
Agitation
Insomnia
Mood symptoms
Psychosis
Dissociation
Somatic complaints

Common symptoms

Although uncommon, some may develop new psychiatric illness during this time
More commonly, psychiatric illness will become an issue due to worsening or re-occurrence of prior such problems
disruption of social and mental health networks
lack of ready medication and care availability
long term intstability - increase in hospitalizations for the severely mentally ill
Acute Phase:
Diagnoses
Stress, Trauma, Disaster
Cognitive flexibility - finding good in adverse situations
Remaining flexible in one’s approach to solving problems
Accepting solutions that may have come from someone else and may not be ideal – but “would do”
Resilience – Cognitive Flexibility

Positive outlook - Using cognitive-behavioral strategies to enhance optimism and decrease pessimism;
Embracing humor – this may seem trivial but makes a major difference
Navy Seals training now utilizes “self-talk” to decrease drop-out rates and maintain resilience.
Resilience – Positive Outlook

Physical exercise - Engaging in physical activity to improve mood and health is key – this is easily available and gives immediate positive feedback to your body and mind that you are in fact in control.
At least 30 minutes of cardio exercise as tolerated – at least 3 times weekly.
Resilience – Exercise

Preparedness before the event, both at work and at home
Monitor your commitment of time and energy during the disaster
Take breaks
Don’t forget to eat, drink, sleep
Don’t ignore your own emotions
Stay in touch with family and friends
Consider means of peer support
Buddy system

Self-Care Tips

Substance Abuse and Mental Health Services Administration

Changes in sleep
Apathetic behavior
Regressive behavior
Changes in relationships with family or peers
Worsening of grades in school
Fears and worries

Children

Most symptoms will have resolved, but a substantial minority will experience the maturation of symptoms from the acute phase

PTSD
Major Depressive Disorder
Anxiety
Substance abuse/dependence
Complicated grief
Adjustment Disorder
Disorders due to medical conditions or unusual medical presentations
Post-Acute Phase
Diagnoses

Cognitive-Behavioral
Prolonged exposure
Traumatic bereavement
Psychodynamic
Group
Family
Psychotherapeutic Techniques

In vitro exposure and cognitive therapy accompanied by rapid eye movements
Increasing evidence for benefits in PTSD
Still unclear what elements are necessary of this structured approach
Little studied in the acute setting
Eye-Movement Desensitization and Re-processing (EMDR)

PFA is the modality of choice for most brief field interventions
Widely adopted by National and International Agencies
"Evidence informed" - very nature of the disasters resists traditional research methods
PFA Focuses is on providing basic safety and autonomy
Community and individual centered approach - capitalizes on strengths and prior experience of coping

Psychological First Aid


Always review current medications, medical problems, and allergies
Emphasis on short-term regimen
Attention to prescriber’s motivations
Pharmacotherapy:
General Principles

dpo
disaster psychiatry outreach

benzodiazepines - useful and ubiquitous and do not appear harmful as was initially thought
hypnotic agents - commonly requested, when possible explore the etiology of the sleep disturbance and utilize CBT
anti-psychotics - may be useful for excessive anxiety and certainly for psychosis
Medications - Experience

dpo
disaster psychiatry outreach

Substance Abuse and Mental Health Services Administration

Avoid technical jargon but be consistent in use of terms
Always indicate level of certainty about information and be honest in answering questions
Avoid false reassurance or pleas not to panic
Pre-event trainings & peri-event updates are crucial for hospital personnel
Provide means of receiving information (TV, radio)
Need areas of quiet as well
Offered interventions should be voluntary, under one’s control, familiar, with clear benefits, conveyed by a trusted source
Communicating in a Crisis

Education regarding basic coping skills and methods must be both effective and timely - may help prevent pathology

Breathe calmly
Avoid making major decisions
Focus on high-priority activities
Resume routines
Avoid alcohol / drugs
Talk honestly with & involve children
Seek help and counseling
If a hospital visit – provide this information upon discharge; prepared sheets are helpful
Psychological First Aid:
Education

WHO, 2004

Families should be kept together
Quarantined patients should have access to information & should have the ability to communicate
Setting up a system or linking with a municipal system for rapid locating of patients’ friends and relatives
Psychological First Aid:
Social Support

Flynn, 2004

Comfort and support
Promote mental health
Accelerate recovery
Prevent a disorder
Treat a disorder

Common Psychological Goals

Suicide / self-harm
Homicide / harm to others
Inability to care for self
Urgent Triage

Dose of trauma: Exposure to the event (death, agony, disfigurement)
Prior psychiatric history
Problems of living prior to the disaster/low socioeconomic status
Lack of perceived or actual social supports after the event
Presence of “secondary stresses”
Female
Middle age
Ethnic minority
Risk Factors for Problems
(DPO Training Course, 2004)

Intense, transient, & fluid
Physical
Palpitations, shortness of breath, dizziness, sweating, loss of appetite,
chest pain
Cognitive
Distractibility, confusion, watchfulness, questions of meaning, expectation of harm, nightmares
Emotional
Fear, anxiety, depression, irritability, fatigue/
exhaustion
Behavioral
Insomnia, interpersonal conflict, agitation, social withdrawal, social dependency, loss of routine,
substance use
Acute Phase:
Common Reactions of Distress
(Berren, Beigel, & Ghertner, 1980)

Cause: Natural vs. human-made
Location: Central vs. peripheral
Duration:
Severity:
Potential for recurrence: unpredictable vs. expected
Sense of Control over future occurrence and consequences
Dimensions of Disaster

Hurricane Katrina was a sudden event with prolonged consequences that inflicted widespread destruction, loss of life, and depleted community resources.

A complex emergency that is beyond the means of self-care of a particular community.
Disaster
Moral compass - Developing and living by meaningful principles;
Putting them into action through altruism/heroism.
Relying on religion to find meaning can be helpful for some.
Resilience – Moral Compass

(Substance Abuse and Mental Health Services Administration, Washington DC)

Unique psychological experiences partly shaped by alterations in routine and parental reactions
Age-dependent reactions
Infants
Pre-school
School-age
Adolescents

Children and Disasters

Antipsychotics should be used for management of acute symptoms of psychosis and mania
Provider should be thoughtful of verifying availability of the specific antipsychotics and continue previous meds whenever verification is possible
Antipsychotics do not seem to have any specific use or special value beyond traditional use
Anti-psychotic medications
"Although SSRIs are effective in chronic PTSD, there is yet no evidence base for their use in the acute disaster setting. Without adequate follow up, SSRIs may provoke mania or even suicidal ideation and therefore are best used only in the post-acute stage."

Anti-Depressants

In the acute phase - the goal is to reduce symptoms that impede coping
Provision of care for those with pre-existing conditions is of high value (strong evidence in increased hospitalizations long after the event)
Adequate pain control (including opiates) likely to decrease later PTSD intensity and incidence
Benzos - may be used judiciously - consider the same thoughtful selection as in every day practice
Pharmacotherapy

Focusing on those who sustained a higher “dose” of the event can facilitate the provision of the services
Physical proximity may be of a great predictive value.
Focus on the most vulnerable - medically compromised elderly, children, isolated minorities
Psychological First Aid:
High-Risk Populations

Brymer et al. 2006

Contact and engagement
Provide for basic needs
Protect from further harm
Reduce agitation & arousal, support those in most distress
Keep families together and provide social support
Provide information, foster communication & education via effective risk communication techniques
Orient to available services
Provide information on coping
Psychological First Aid

(Institute of Medicine, 2003)

Distress response
– changes in how people think and feel
Behavioral changes
– changes in how people go about their life and do things
Psychiatric illness
– at the most extreme end of response and behavioral changes and include Post-Traumatic Stress Disorder or Major Depression
Psychological Consequences of Concern
= a spectrum
(Taylor, 1987; Wright et al., 1990)

Disaster Community
Adopted from “6 Keys to Resilience for PTSD and every day stress, Margaret Haglund, BA, Current Psychiatry,

Active Coping Style
Physical Exercise
Positive Outlook
Moral Compass
Social Support
Cognitive Flexibility

Resilience

Example:

Propranolol
Hydrocortisone
SSRI, SNRI, TCA
Benzodiazepines
Morphine
Antagonist/agonists

(Bennett et al. 2007)

Acute Pharmacotherapy – Secondary Prevention

dpo
disaster psychiatry outreach

(Katz and Yehuda, 2004)

May initially be adaptive and “normal” (i.e. “fight or flight reaction”)
In contrast, persistence and functional impact help to gauge whether they are “abnormal”
Acute Phase:
Common Symptoms
(Wolfenstein, 1957)
(Katz et al, 2002)

Bewilderment
Danger
Confusion
Impasse
Desperation
Apathy
Helplessness
Urgency
Discomfort
“Stunned”
“Shocked”
Feeling abandoned
Uncommon vulnerability

Intense love / altruism
Heroism / Industry
Acute Psychological Responses

Disaster...
Despite a generally positive sense we have around the term "community" - this one is traumatized, chaotic, poorly established, with fragmented access to information and services. Special and early attention must be payed to the dinamics of such a community.
Courtesy of Marko Georgiev for the New York Times
Interventions
Acute Stress Disorder
Major Depression
Reactivated PTSD
Acute Bereavement
Adjustment Disorder
Culturally codified phenomena
Panic Attacks
Personality disorder coping problems
Brief Psychotic Disorder
Substance Abuse
Delirium
Disaster Psychiatry: Readiness, Evaluation, and Treatment 2011
(Neria et al. 2008)
Elderly
Once basic safety is provided - older individuals can be an important pillar of stability for families and community
Life experience can be an example of resilience and recovery
Rapid and safe involvement in routine and provision for medical needs is key
Resilience and Special Populations
www.disasterpsych.org
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