The Role Consultation Liaison Services when Disaster Strikes A C McFarlane AO Professor of Psychiatry Centre for Traumatic Stress Studies The University of Adelaide

The Nature of Disasters  Collective social suffering, reinforce sense of collective interest  Demonstrate the limits of technology to control  Less stigmatisation of victims than singular events and confront vulnerability  Benchmarks in history of communities

Tangshan Earthquake  28th July 1976     242,000 dead and 164,000 badly injured Gang of Four - media propaganda concern for victims Earthquake phobia lead to major activism throughout the country Slogans read: “Be alert to Deng Xiaoping’s criminal attempt to exploit earthquake phobia to suppress revolution!” “There were several hundred thousand deaths. So what? Denouncing Deng Xiaoping concerns eight hundred million” 6/10/1976 Mme Mao arrested  pg 65-66 Wild Swans, Jung Chang

1983 Ash Wednesday Bushfires  808 Primary school children  2600 registered disaster victims  459 CFS firefighters  320 patients  Interviewed the departmental relief co coordinators  Surveyed disaster relief teams  Post disaster litigation

Disaster Experience            Melbourne/Voyager 82 men killed 1964 Ash Wednesday Bushfire Disaster Yunnan Earthquake 800 deaths Iraqi invasion of Kuwait Kobe earthquake 3000 deaths Bali Bombing 82 deaths and second bombing Port Arthur Massacre - single most killings by a single gunman Australian Defence Force - soldiers in peace keeping in Rawanda and Timor and Middle East Area of Operations Boxing Day Tsunami 2005 Eyre Peninsula and Black Saturday Bushfires 2009 Mine accident, roof collapse in golf club, school bus accident,shooting of doctor, murder of director of mental health services, ship wrecks, show ride collapse, rail accidents.

Disasters: Lessons for Service Delivery  Predictable morbidity in exposed population – Vary for degree of exposure and losses  Optimal public health intervention – Population based – Primary and secondary prevention – Evidence based treatments

Time Windows of Service Planning  Pre-traumatic  Warning  Traumatic exposure  Acute posttraumatic / Rescue  Medium term period / Recovery  Chronic phase of readjustment or re-establishment of life.

Post Disaster Service Delivery  The consultant and relationship with postdisaster planner  The role and skills of the service providers  The expectations of the victims/patients

Acute Post disaster Rescue Phase

Disasters in Context  What are the mental health services in the affected areas?

 How adequately do they meet the existing need in those communities?

 If a post disaster mental health program is put in place, will that add to or take away from existing services  Ensure that any initiatives improve the existing delivery of services

Debriefing  Not effective and should not be practiced  Encourages short-term focus of media and health services  Screening is the central strategy

Time Frames of Service Demand ACUTE/ RESCUE MEDIUM/ RECOVERY CHRONIC/ RESTORAT N Medical Services ++++ + Rehab Treatment Psychiatry Services + ++ + ++ +++

Victims Reaction to Symptoms  To be expected  Time will improve  Demand for self hardiness  Stigma and shame  Avoidance  Confusion about the meaning of experience - onset of somatic symptoms

Medium term recovery phase

Role of Primary Health Care Networks  Victims prefer to use the existing health care providers  Good quality care for physical injuries and adequate pain management  Do not compete with but integrate with their service delivery and locations, if possible  Support and educate

Saw doctor about physical health complaint Respiratory Musculoskeletal Cardiovascular Gastrointestinal Dermatological Urological Headaches & funny turns * P<0.05

PTSD No PTSD (n = 77) 19% (n = 70) 4% 39% 14% 13% 22% 9% 6% 17% 1% 17% 9% 4% 9% **P<0.01

6.69 * 4.00 ** 0.52

1.06

1.46

0.16

1.45

Organizational Issues  Managing the politics of the health care system and disaster relief  Leadership and expertise - new structures and response paradigms  Effective interaction with disaster managers and emergency service leaders in future disaster planning  Managing positive outcomes in a compensation environment

Chronic posttraumatic re establishment phase

Chronic posttraumatic/Re establishment phase  Withdrawal of public interest  Maintenance of recognition of special needs of community  Reintegration into the mainstream structures  Sustaining expertise to be used with the victims of singular events

Identification of Post Disaster Morbidity

SUBCLINICAL UNKNOWN DISORDER KNOWN DISORDER TOTAL DISASTER POPULATION

Screening after London Bombings       Problems of getting access to population Defined high risk groups 71% screened positive PTSD the predominant diagnosis Treatment given to 82 with large effect size More referrals from screening than GPs who had been contacted  Brewin et al, 2008 Journal fo Traumatic Stress, 21 3-8

Public Health Perspective  The possible interventions – Do not over-estimate value of prevention  Planning and coordination – Part of general health policy  The identification of those at risk  Need a mental health literacy program

The issue of the pattern of onset PTSD Severe acute distress is the exception and progressive increase of symptoms is very common

Percentage of psychiatric cases in children after a bushfire

Prevalence of PTSD after a mass traumatic event 18 16 14 2 0 6 4 12 10 8 Oct-Nov 2001 Jan-Feb 2002 Mar-June 2002 Sept 2002-Jan 2003 Sept 2003-Feb 2004 Dec 2004 - Nov 2005

Trajectory of PTS symptoms, with probabilities 14 12 10 8 6 4

10.9% 6.2% 19.4%

2 0 0 5 10 15 20 25

Months since Sept 11 2001

30

Norris FH, Tracy M, Galea S. Psychological resilience as a trajectory: Evidence from two major disasters. Social Science & Medicine. In Press.

8.5% 7.6% 6.7% 40.7%

35 40 45

Course of PTSD symptoms after 9/11 (Norris et al, 2009)  1267 with all 4 data points up to 42 months  Decreasing 19.4%  Increasing 37.2%  Stable very little distress 40.1% No distress or increasing symptoms is the most common pattern of response

Progression of cases at 24 months in accident and work injuries n=96   At 3 months 35.9% had full diagnosis » 44.1% reported minimal symptoms At 12 months 49% had full diagnosis » 26.7% reported minimal symptoms   There is a progressive emergence of disorder at with time which means there is a need for repeated reassessment Coping in the immediate aftermath does not mean an individual will not develop PTSD or chronic pain later

60 Month Follow Up Chronic 4.0% Delayed onset 9.6% Delayed onset (resolving) 8.1% Acute resolving 5.7% No symptoms 72.5%

The Conceptual Challenge Posed by Traumatic Stress  Individuals who coped at the time of stress exposure became unwell many years later  What model of psychopathology could account for this lingering and delayed impact of extreme adversity?

 The issue of delayed onset PTSD

The issue of delayed onset PTSD Severe acute distress is the exception and progressive increase of symptoms is very common

Posttraumatic Sensitization Disorder The risk of PTSD following first exposures is less than later exposures

Do not forget the background psychiatric morbidity of the population

Post Disaster Morbidity

Total Population Other Psychiatric Disorder PTSD Traumatic Event

2007 ABS National Epidemiology Survey   8,841 people - 60% response rate Over 16 years - life time and 12 month prevalence » 45% had a life time disorder » 20% 12 month prevalence  26% of young adults (16-24) 12 month prevalence  Anxiety disorders 14.4%    Affective disorder 6.2% - Depressive episode 4.1% Most common disorder - PTSD 6.4% Substance Use Disorder 5.1% » » Alcohol harmful use 2.9% Alcohol dependence 1.4%

GHQ cases 5 months after Yunnan Earthquake Control n=908 Disaster group n=1294

The Challenge to Maintain Postdisaster Skills  Extend the treatment skills and health service delivery system developed after the disaster into other appropriate settings » Individual trauma victims and chronically mentally ill  To plan for the next disaster and to set training and health care plans  To modify services and plans in light of emerging research

Disasters v’s Individual Trauma

Disasters Individual Traumatic events Car Accidents Victims of Crime Military Rape victims Child abuse Torture Victims Mental Health Resources Specialized trauma Services Consultation and liaison services

The quality of research ?decreasing as the field matures  Norris 2006 Journal of Traumatic Stress  225 disaster studies  Fewer using longitudinal studies and representative samples  Early assessments have been increasing  Need to attend to the fundamentals of epidemiological research

Design type by year: The proportion of longitudinal studies has been

decreasing

Norris 2006

Black Saturday 7 th February 2009

Impact of Change of Wind Direction

Similarity of Weather Systems  Ash Wednesday Black Saturday

Black Saturday  48 hours before the Premier highlighted the extraordinary fire risk  Headline on day of the disaster-before the fires “Worst day in History”  173 People killed  2,600 buildings destroyed  Area 1.1 million acres – Japan is 93 mil  Injured 600 +

Ash Wednesday Disaster  75 people killed  2676 injured  Over 3700 buildings destroyed  1,032,000 acres burnt

Lessons Learnt  Academic Study of mental health outcomes does not record critical issues for survival behaviour  Warnings are not expressed in language or forms that change behaviour  Journalists do not record or report critical facts  Failure to learn from past lessons

The role of mental health professionals  Collectors of isolated stories  Need for case studies  Advocacy role for communities and victims  Issues of insurance and the rhetoric of commercial interests  Self serving media management by government does not encourage facing the failures and learning

Problems with the field  The long term course is not adequately considered  What conveys the long term risk?

 The issue of trauma and other disorders- is the risk specific to PTSD?

 Missing lessons of the past and reinventing what is know

The Conceptual Challenge Posed by Traumatic Stress in Disasters  Individuals who coped at the time of stress exposure became unwell many years later » Delayed onset is very common and underestimated  What model of psychopathology could account for this lingering and delayed impact of extreme adversity?

» Sensitization and allostatic load / vulnerable to stress

Thank you

Prof AC McFarlane Centre of Military and Veterans Health The University of Adelaide 122 Frome Street Adelaide South Australia Australia 5000 Telephone 61 88303 5200 Fax 61 88303 5368 Email [email protected]