The Role Consultation Liaison The Role Consultation Liaison Services when Disaster Strikes Services when Disaster Strikes
A C McFarlane AOA C McFarlane AO
Professor of PsychiatryProfessor of Psychiatry
Centre for Traumatic Stress StudiesCentre for Traumatic Stress Studies
The University of Adelaide The University of Adelaide
The Nature of DisastersThe Nature of Disasters
Collective social suffering, reinforce sense of Collective social suffering, reinforce sense of
collective interestcollective interest
Demonstrate the limits of technology to controlDemonstrate the limits of technology to control
Less stigmatisation of victims than singular Less stigmatisation of victims than singular
events and confront vulnerabilityevents and confront vulnerability
Benchmarks in history of communitiesBenchmarks in history of communities
Tangshan EarthquakeTangshan Earthquake
28th July 197628th July 1976
242,000 dead and 164,000 badly injured242,000 dead and 164,000 badly injured
Gang of Four - media propaganda concern for victimsGang of Four - media propaganda concern for victims
Earthquake phobia lead to major activism throughout the countryEarthquake phobia lead to major activism throughout the country
Slogans read: “Be alert to Deng Xiaoping’s criminal attempt to exploit Slogans read: “Be alert to Deng Xiaoping’s criminal attempt to exploit
earthquake phobia to suppress revolution!”earthquake phobia to suppress revolution!”
““There were several hundred thousand deaths. So what? Denouncing There were several hundred thousand deaths. So what? Denouncing
Deng Xiaoping concerns eight hundred million” Deng Xiaoping concerns eight hundred million”
6/10/1976 Mme Mao arrested6/10/1976 Mme Mao arrested pg 65-66 Wild Swans, Jung Changpg 65-66 Wild Swans, Jung Chang
1983 Ash Wednesday Bushfires1983 Ash Wednesday Bushfires
808 Primary school children808 Primary school children 2600 registered disaster victims2600 registered disaster victims 459 CFS firefighters459 CFS firefighters 320 patients320 patients Interviewed the departmental relief co-Interviewed the departmental relief co-
coordinatorscoordinators Surveyed disaster relief teamsSurveyed disaster relief teams Post disaster litigation Post disaster litigation
Disaster ExperienceDisaster Experience
Melbourne/Voyager 82 men killed 1964Melbourne/Voyager 82 men killed 1964 Ash Wednesday Bushfire Disaster Ash Wednesday Bushfire Disaster Yunnan Earthquake 800 deathsYunnan Earthquake 800 deaths Iraqi invasion of KuwaitIraqi invasion of Kuwait Kobe earthquake 3000 deathsKobe earthquake 3000 deaths Bali Bombing 82 deaths and second bombingBali Bombing 82 deaths and second bombing Port Arthur Massacre - single most killings by a single gunmanPort Arthur Massacre - single most killings by a single gunman Australian Defence Force - soldiers in peace keeping in Rawanda Australian Defence Force - soldiers in peace keeping in Rawanda
and Timor and Middle East Area of Operationsand Timor and Middle East Area of Operations Boxing Day Tsunami 2005Boxing Day Tsunami 2005 Eyre Peninsula and Black Saturday Bushfires 2009Eyre Peninsula and Black Saturday Bushfires 2009 Mine accident, roof collapse in golf club, school bus Mine accident, roof collapse in golf club, school bus
accident,shooting of doctor, murder of director of mental health accident,shooting of doctor, murder of director of mental health services, ship wrecks, show ride collapse, rail accidents.services, ship wrecks, show ride collapse, rail accidents.
Disasters: Lessons for Service DeliveryDisasters: Lessons for Service Delivery
Predictable morbidity in exposed populationPredictable morbidity in exposed population– Vary for degree of exposure and lossesVary for degree of exposure and losses
Optimal public health interventionOptimal public health intervention– Population basedPopulation based
– Primary and secondary preventionPrimary and secondary prevention
– Evidence based treatmentsEvidence based treatments
Time Windows of Service PlanningTime Windows of Service Planning
Pre-traumaticPre-traumatic WarningWarning Traumatic exposureTraumatic exposure Acute posttraumatic / RescueAcute posttraumatic / Rescue Medium term period / RecoveryMedium term period / Recovery Chronic phase of readjustment Chronic phase of readjustment
or re-establishment of life. or re-establishment of life.
Post Disaster Service DeliveryPost Disaster Service Delivery
The consultant and relationship with The consultant and relationship with postdisaster plannerpostdisaster planner
The role and skills of the service The role and skills of the service providersproviders
The expectations of the victims/patientsThe expectations of the victims/patients
Disasters in ContextDisasters in Context
What are the mental health services in the What are the mental health services in the affected areas?affected areas?
How adequately do they meet the existing How adequately do they meet the existing need in those communities?need in those communities?
If a post disaster mental health program is put If a post disaster mental health program is put in place, will that add to or take away from in place, will that add to or take away from existing servicesexisting services
Ensure that any initiatives improve the Ensure that any initiatives improve the existing delivery of servicesexisting delivery of services
DebriefingDebriefing
Not effective and should not be Not effective and should not be practicedpracticed
Encourages short-term focus of media Encourages short-term focus of media and health servicesand health services
Screening is the central strategyScreening is the central strategy
Time Frames of Service DemandTime Frames of Service Demand
MedicalMedical
ServicesServices
RehabRehab
TreatmentTreatment
PsychiatryPsychiatry
ServicesServices
ACUTE/ACUTE/
RESCUERESCUE
++++++++ -- ++
MEDIUM/MEDIUM/
RECOVERYRECOVERY
++ ++++ ++++
CHRONIC/CHRONIC/
RESTORATRESTORATNN
-- ++ ++++++
Victims Reaction to SymptomsVictims Reaction to Symptoms
To be expectedTo be expected Time will improveTime will improve Demand for self hardinessDemand for self hardiness Stigma and shameStigma and shame AvoidanceAvoidance Confusion about the meaning of Confusion about the meaning of
experience - onset of somatic symptomsexperience - onset of somatic symptoms
Role of Primary Health Care Role of Primary Health Care NetworksNetworks
Victims prefer to use the existing health Victims prefer to use the existing health care providerscare providers
Good quality care for physical injuries Good quality care for physical injuries and adequate pain managementand adequate pain management
Do not compete with but integrate with Do not compete with but integrate with their service delivery and locations, if their service delivery and locations, if possiblepossible
Support and educateSupport and educate
Saw doctor about physical health complaintSaw doctor about physical health complaint
PTSD PTSD No PTSDNo PTSD(n = 77)(n = 77) (n = 70)(n = 70)
RespiratoryRespiratory 19%19% 4% 4% 6.69 *6.69 *MusculoskeletalMusculoskeletal 39%39% 22%22% 4.00 **4.00 **CardiovascularCardiovascular 14%14% 9% 9% 0.520.52GastrointestinalGastrointestinal 13%13% 6% 6% 1.061.06DermatologicalDermatological 17%17% 9% 9% 1.461.46UrologicalUrological 1% 1% 4% 4% 0.160.16Headaches & funny turnsHeadaches & funny turns 17%17% 9% 9% 1.451.45
* P<0.05* P<0.05 **P<0.01**P<0.01
Organizational IssuesOrganizational Issues
Managing the politics of the health care Managing the politics of the health care system and disaster reliefsystem and disaster relief
Leadership and expertise - new structures Leadership and expertise - new structures and response paradigmsand response paradigms
Effective interaction with disaster managers Effective interaction with disaster managers and emergency service leaders in future and emergency service leaders in future disaster planningdisaster planning
Managing positive outcomes in a Managing positive outcomes in a compensation environmentcompensation environment
Chronic posttraumatic/Re-Chronic posttraumatic/Re-establishment phaseestablishment phase
Withdrawal of public interestWithdrawal of public interest Maintenance of recognition of Maintenance of recognition of
special needs of communityspecial needs of community Reintegration into the mainstream Reintegration into the mainstream
structuresstructures Sustaining expertise to be used Sustaining expertise to be used
with the victims of singular eventswith the victims of singular events
Identification of Post Disaster Identification of Post Disaster MorbidityMorbidity
KNOWNKNOWNDISORDERDISORDER
SUBCLINICALSUBCLINICAL UNKNOWNUNKNOWNDISORDERDISORDER
TOTAL DISASTER POPULATIONTOTAL DISASTER POPULATION
Screening after London BombingsScreening after London Bombings
Problems of getting access to populationProblems of getting access to population Defined high risk groupsDefined high risk groups 71% screened positive71% screened positive PTSD the predominant diagnosisPTSD the predominant diagnosis Treatment given to 82 with large effect sizeTreatment given to 82 with large effect size More referrals from screening than GPs who had More referrals from screening than GPs who had
been contactedbeen contacted Brewin et al, 2008 Journal fo Traumatic Stress, 21 3-8Brewin et al, 2008 Journal fo Traumatic Stress, 21 3-8
Public Health PerspectivePublic Health Perspective
The possible interventionsThe possible interventions– Do not over-estimate value of preventionDo not over-estimate value of prevention
Planning and coordinationPlanning and coordination– Part of general health policyPart of general health policy
The identification of those at riskThe identification of those at risk Need a mental health literacy programNeed a mental health literacy program
The issue of the pattern of onset The issue of the pattern of onset PTSDPTSD
Severe acute distress is the exception Severe acute distress is the exception and progressive increase of symptoms and progressive increase of symptoms
is very commonis very common
Percentage of psychiatric cases in Percentage of psychiatric cases in children after a bushfirechildren after a bushfire
Trajectory of PTS symptoms, with probabilitiesTrajectory of PTS symptoms, with probabilities
40.7%
6.7%
19.4%
7.6%
10.9%
8.5%
6.2%
Norris FH, Tracy M, Galea S. Psychological resilience as a trajectory: Evidence from two major disasters. Social Science & Medicine. In Press.
Course of PTSD symptoms after Course of PTSD symptoms after 9/11 (Norris et al, 2009)9/11 (Norris et al, 2009)
1267 with all 4 data points up to 42 1267 with all 4 data points up to 42 monthsmonths
Decreasing 19.4%Decreasing 19.4% Increasing 37.2%Increasing 37.2% Stable very little distress 40.1%Stable very little distress 40.1%
No distress or increasing symptoms is the No distress or increasing symptoms is the most common pattern of responsemost common pattern of response
Progression of cases at 24 months in accident Progression of cases at 24 months in accident and work injuries n=96and work injuries n=96
At 3 months 35.9% had full diagnosis At 3 months 35.9% had full diagnosis » 44.1% reported minimal symptoms44.1% reported minimal symptoms
At 12 months 49% had full diagnosisAt 12 months 49% had full diagnosis» 26.7% reported minimal symptoms26.7% reported minimal symptoms
There is a progressive emergence of disorder at with There is a progressive emergence of disorder at with time which means there is a need for repeated time which means there is a need for repeated reassessmentreassessment
Coping in the immediate aftermath does not mean an Coping in the immediate aftermath does not mean an individual will not develop PTSD or chronic pain laterindividual will not develop PTSD or chronic pain later
60 Month Follow Up60 Month Follow Up
Chronic 4.0%
Delayed onset 9.6%
Delayed onset(resolving) 8.1%
No symptoms 72.5%
Acute resolving 5.7%
The Conceptual Challenge Posed The Conceptual Challenge Posed by Traumatic Stressby Traumatic Stress
Individuals who coped at the time of Individuals who coped at the time of stress exposure became unwell many stress exposure became unwell many years lateryears later
What model of psychopathology could What model of psychopathology could account for this lingering and delayed account for this lingering and delayed impact of extreme adversity?impact of extreme adversity?
The issue of delayed onset PTSDThe issue of delayed onset PTSD
The issue of delayed onset PTSDThe issue of delayed onset PTSD
Severe acute distress is the exception Severe acute distress is the exception and progressive increase of symptoms and progressive increase of symptoms
is very commonis very common
Posttraumatic Sensitization DisorderPosttraumatic Sensitization Disorder
The risk of PTSD following first The risk of PTSD following first exposures is less than later exposuresexposures is less than later exposures
Do not forget the background Do not forget the background psychiatric morbidity of the populationpsychiatric morbidity of the population
Post Disaster MorbidityPost Disaster Morbidity
PTSDPTSD
Traumatic EventTraumatic Event
Other Psychiatric Other Psychiatric DisorderDisorder
Total PopulationTotal Population
2007 ABS National Epidemiology Survey2007 ABS National Epidemiology Survey
8,841 people - 60% response rate8,841 people - 60% response rate Over 16 years - life time and 12 month prevalenceOver 16 years - life time and 12 month prevalence
» 45% had a life time disorder45% had a life time disorder» 20% 12 month prevalence20% 12 month prevalence
26% of young adults (16-24)26% of young adults (16-24)12 month prevalence12 month prevalence Anxiety disorders 14.4%Anxiety disorders 14.4% Affective disorder 6.2% - Depressive episode 4.1%Affective disorder 6.2% - Depressive episode 4.1% Most common disorderMost common disorder
- PTSD 6.4%- PTSD 6.4% Substance Use Disorder 5.1%Substance Use Disorder 5.1%
» Alcohol harmful use 2.9%Alcohol harmful use 2.9%» Alcohol dependence 1.4%Alcohol dependence 1.4%
GHQ cases 5 months after GHQ cases 5 months after Yunnan Earthquake Yunnan Earthquake
Control n=908Control n=908Disaster group n=1294Disaster group n=1294
The Challenge to Maintain The Challenge to Maintain Postdisaster SkillsPostdisaster Skills
Extend the treatment skills and health service delivery Extend the treatment skills and health service delivery
system developed after the disaster into other system developed after the disaster into other
appropriate settings appropriate settings
» Individual trauma victims and chronically mentally illIndividual trauma victims and chronically mentally ill
To plan for the next disaster and to set training and To plan for the next disaster and to set training and
health care planshealth care plans
To modify services and plans in light of emerging To modify services and plans in light of emerging
researchresearch
Disasters v’s Individual TraumaDisasters v’s Individual Trauma
DisastersDisastersIndividual Traumatic eventsIndividual Traumatic events
Car AccidentsCar AccidentsVictims of CrimeVictims of Crime
MilitaryMilitaryRape victimsRape victimsChild abuseChild abuse
Torture VictimsTorture VictimsMental Health ResourcesMental Health Resources
Specialized trauma Specialized trauma ServicesServices
Consultation and liaisonConsultation and liaisonservicesservices
The quality of research ?The quality of research ?decreasing as the field maturesdecreasing as the field matures
Norris 2006 Journal of Traumatic StressNorris 2006 Journal of Traumatic Stress 225 disaster studies225 disaster studies Fewer using longitudinal studies and Fewer using longitudinal studies and
representative samplesrepresentative samples Early assessments have been Early assessments have been
increasingincreasing Need to attend to the fundamentals of Need to attend to the fundamentals of
epidemiological research epidemiological research
Design type by year: The proportion of Design type by year: The proportion of longitudinal studies has been longitudinal studies has been decreasingdecreasing
Norris 2006
Similarity of Weather SystemsSimilarity of Weather Systems
Ash WednesdayAsh Wednesday Black SaturdayBlack Saturday
Black SaturdayBlack Saturday
48 hours before the Premier highlighted 48 hours before the Premier highlighted the extraordinary fire risk the extraordinary fire risk
Headline on day of the disaster-before Headline on day of the disaster-before the fires- “Worst day in History”the fires- “Worst day in History”
173 People killed173 People killed 2,600 buildings destroyed2,600 buildings destroyed Area 1.1 million acres – Japan is 93 milArea 1.1 million acres – Japan is 93 mil Injured 600 +Injured 600 +
Ash Wednesday DisasterAsh Wednesday Disaster
75 people killed75 people killed 2676 injured2676 injured Over 3700 buildings destroyedOver 3700 buildings destroyed 1,032,000 acres burnt1,032,000 acres burnt
Lessons LearntLessons Learnt
Academic Study of mental health Academic Study of mental health outcomes does not record critical issues outcomes does not record critical issues for survival behaviourfor survival behaviour
Warnings are not expressed in language Warnings are not expressed in language or forms that change behaviouror forms that change behaviour
Journalists do not record or report Journalists do not record or report critical factscritical facts
Failure to learn from past lessonsFailure to learn from past lessons
The role of mental health The role of mental health professionalsprofessionals
Collectors of isolated storiesCollectors of isolated stories Need for case studiesNeed for case studies Advocacy role for communities and victimsAdvocacy role for communities and victims Issues of insurance and the rhetoric of Issues of insurance and the rhetoric of
commercial interestscommercial interests Self serving media management by Self serving media management by
government does not encourage facing government does not encourage facing the failures and learningthe failures and learning
Problems with the fieldProblems with the field
The long term course is not adequately The long term course is not adequately consideredconsidered
What conveys the long term risk?What conveys the long term risk? The issue of trauma and other The issue of trauma and other
disorders- is the risk specific to PTSD?disorders- is the risk specific to PTSD? Missing lessons of the past and Missing lessons of the past and
reinventing what is knowreinventing what is know
The Conceptual Challenge Posed The Conceptual Challenge Posed by Traumatic Stress in Disastersby 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
Prof AC McFarlaneProf AC McFarlane
Centre of Military and Veterans HealthCentre of Military and Veterans HealthThe University of AdelaideThe University of Adelaide122 Frome Street 122 Frome Street AdelaideAdelaideSouth Australia South Australia Australia 5000Australia 5000Telephone 61 88303 5200Telephone 61 88303 5200Fax 61 88303 5368Fax 61 88303 5368Email [email protected] [email protected]