Transcript Document

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
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Collective social suffering, reinforce sense of
collective interest
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Demonstrate the limits of technology to control
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Less stigmatisation of victims than singular
events and confront vulnerability
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Benchmarks in history of communities
Tangshan Earthquake
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28th July 1976
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242,000 dead and 164,000 badly injured
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Gang of Four - media propaganda concern for victims
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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”
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6/10/1976 Mme Mao arrested
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pg 65-66 Wild Swans, Jung Chang
1983 Ash Wednesday Bushfires
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808 Primary school children
2600 registered disaster victims
459 CFS firefighters
320 patients
Interviewed the departmental relief cocoordinators
Surveyed disaster relief teams
Post disaster litigation
Disaster Experience
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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
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Predictable morbidity in exposed population
– Vary for degree of exposure and losses
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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.
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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
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Acute Post disaster Rescue Phase
Disasters in Context
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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
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Time Frames of Service Demand
ACUTE/
RESCUE
MEDIUM/
RECOVERY
CHRONIC/
RESTORATN
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
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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
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Saw doctor about physical health complaint
PTSD No PTSD
Respiratory
Musculoskeletal
Cardiovascular
Gastrointestinal
Dermatological
Urological
Headaches & funny turns
* P<0.05
(n = 77)
(n = 70)
19%
39%
14%
13%
17%
1%
17%
4%
22%
9%
6%
9%
4%
9%
**P<0.01
6.69 *
4.00 **
0.52
1.06
1.46
0.16
1.45
Organizational Issues
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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 reestablishment phase
Chronic posttraumatic/Reestablishment 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
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Identification of Post Disaster
Morbidity
SUBCLINICAL
UNKNOWN
DISORDER
KNOWN
DISORDER
TOTAL DISASTER POPULATION
Screening after London Bombings
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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
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Brewin et al, 2008 Journal fo Traumatic Stress, 21 3-8
Public Health Perspective
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The possible interventions
– Do not over-estimate value of prevention
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Planning and coordination
– Part of general health policy
The identification of those at risk
 Need a mental health literacy program
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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
Prevalence of current PTSD
14
12
10
8
6
4
2
0
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
8.5%
12
PTSD symptoms
10
7.6%
8
6
10.9%
6.7%
4
19.4%
6.2%
2
40.7%
0
0
5
10
15
20
25
30
Months since Sept 11 2001
Norris FH, Tracy M, Galea S. Psychological resilience as a trajectory: Evidence from two major disasters. Social Science & Medicine. In Press.
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%
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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
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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
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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
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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%
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» 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
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Extend the treatment skills and health service delivery
system developed after the disaster into other
appropriate settings
» Individual trauma victims and chronically mentally ill
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To plan for the next disaster and to set training and
health care plans
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To modify services and plans in light of emerging
research
Disasters v’s Individual Trauma
Disasters
Mental Health Resources
Specialized trauma
Services
Consultation and liaison
services
Individual Traumatic events
Car Accidents
Victims of Crime
Military
Rape victims
Child abuse
Torture Victims
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
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Design type by year: The proportion of
longitudinal studies has been decreasing
Norris 2006
Black Saturday
7th February 2009
Impact of Change of Wind
Direction
Similarity of Weather Systems
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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 +
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Ash Wednesday Disaster
75 people killed
 2676 injured
 Over 3700 buildings destroyed
 1,032,000 acres burnt
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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
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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
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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
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The Conceptual Challenge Posed
by Traumatic Stress in Disasters
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Individuals who coped at the time of stress
exposure became unwell many years later
» Delayed onset is very common and underestimated
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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]