Integrating Ethical Research and Practice in Disaster Mental Health

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Integrating Ethical Research and Practice in
Disaster Mental Health

• Peykan G. Gökalp
• Bakirkoy Research and
• Training Hospital for
• Psychiatry and Neurology
• Istanbul - Turkey

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Main points

• Disaster studies from Turkey
• Overall conclusion of the studies
• ADEPSTEP, a services project on disaster mental
  health
• Some Q A on ethics and disaster research
• Ethical evaluation of ADEPSTEP ( a model)

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Disaster and Mental Health

• Disasters strike the well being, infrastructure,
  economy and most of all mental health of the
  community
• Mental health services are not taylored for
  disaster survivors and working on the field.

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Studies before 1999

• Effects of the eathquake on the social structure
  of the society Örnek et al. (1971) Burdur
• PTSD in earthquake survivors
• Veznedaroglu et al. (1993) Erzincan 93
• Correlates of earthquake cognition and
  preparedness in a victimized population
• Rustemli Karanci (1999) Erzincan 93
• Dinar Earthquake and Expectations from Godot
• Aksit et al. 1997 Dinar 95
• Preliminary report of stressor effects on
  adolescent survivors of Dinar Earthquake Sener
  at al. (1997)
• The investigation of acute stress disorder after
  the 1998 Adana earthquake.
• Uguz et al. (2000) Adana 98

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Disaster Studies in Turkey

• 1971 Burdur Earthquake (6.2)
• Effects of the earthquake on the social
  structure of the society
• Örnek et al. (1971)
• 3 Psychiatrists made face to face interviews
  with 150 survivors in the first week after the
  disaster.
• Results social classes moved closer, the feeling
  of solidarity increased.
• 88 felt confusion,
• 15 stood still,
• 63 participated in rescue work
• Audio records were made

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1999 Marmara Earthquake (7.4)

• Ayatan 2000
• Dindar 2000
• Yucel et al. 2000
• ADEPSTEP (Adapazari) 2001
• Hacioglu 2001
• Unlugedik 2001
• Yigit 2000 GATA
• Sezgin Yuksel 2001
• Tural et al. 2001
• Basoglu et al. 2002
• Karamustafalioglu et al. 2002
• Basoglu et al. 2003
• Özguler 2003
• Salcioglu et al. 2003

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Risk factors for PTSD

• Ayatan 2000
• n151 (72.8 female, 27.2 male)
• 20 (13.2) saved from the rubbles,
• 38 (25.2) was wounded,
• 21 (13.9) lost at least one member of the family
• Risk factors low education, rescuers, history of
  an anxiety disorder,

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PTSD predictors

• Dindar 2000 3 weeks after the eq, n283 (61.5
  female, 38.5 male)
• Mean age 32.68 12.22
• The immediate physiologic responses (tremor /
  trembling) to the eq were significantly related
  to PTSD symptomatology.

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The relationship between early phase PTSD
symptoms and predicting factors

• Ünlügedik 2001
• N 285 (61.5 female, 38.5 male ), interviews
  were conducted in 3 wk. after the eq.
• Mean age 32.68 12.22
• Gender (female) is the most powerful predictor
  for symptom severity

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Comorbidity in PTSD

• Tural et al. 2001
• N 76 (68.4 female, 31.6 male)
• Mean age41.5811.24
• Severely traumatized population
• 44.7 saved from the rubbles, 9.2 severely
  wounded, 23.7 lost a first degree relative, 22.4
  had a first degree relative with a psychiatric
  disorder.
• 38.2 had a comorbid disorder
• 28.9 had a secondary m. Depression
• Predictors for comorbidity loss of a close rel,
  physical damage, being female, experiencing
  severe fear of death

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The natural course of PTSD

• Karamustafalioglu et al. 2003
• a follow up study conducted in Avcilar- Istanbul.
• 9 422 people screened in the first 3 months, 38.8
  PTSD.
• 15 453 people screened in the 6-8. months post
  disaster, 23.8 PTSD.
• 15 597 was screened in the 18-20. months, 8.1
  had PTSD.
• The prevalence rate of PTSD decreased with time.

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Predictors of PTSD symptom severity

• Salcioglu et al. 2003 (J Nerv Ment Dis)
• Prevalence rate of PTSD and Depression was
  studied at 20. month after the eq
• 586 were screened, who lived in a prefabricated
  village
• 39 had PTSD, 18 had depression
• PTSD symptom severity was higher in women,
  elderly, rescuers, who had a psychiatric history,
  who were saved from the rubble and who felt an
  overwhelming fear.

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PTSD in elderly disaster survivors

• Özgüler 2003
• n90
• 51 survivors(18-55 yo)
• 39 survivors (gt60 yo), who fullfilled DSM lV PTSD
  criteria
• The symptom severity and frequency decreased with
  age, younger adults had more comorbid diagnoses.

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Common features of the studies

• Focused on the prevalence of PTSD
• Most published data have follow-up assessments
• Predictors for PTSD were discussed
• Majority have unselected population in the
  community as samples
• Small number of research on population from
  mental health services.

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Disaster studies with child survivors after 1999

• Berkem Bildik 2001
• Yorbik at al. 1999
• Laor et al. 2002 (Y.Yazgan)
• Alyanak et al. 2000
• Wolmer et al. 2003 (Y. Yazgan)
• Yorbik et al. 2004

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Child adolescent studiesOverall conclusion

• The perception and response to trauma differs
  according to developmental factors.
• DSM-IV criteria are insufficient to diagnose PTSD
  for preschool children
• Sleep disorders and pains were more frequent with
  physical trauma
• The duration of staying in the rubbles caused
  emotional isolation
• Trained teachers can help MH professionals in
  determining child survivors of disaster who
  needed help

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Emirdag Prefabricated VillageAdapazari

• Population3000
• Number of houses 425
• Area of a house 36m2
• Social service houses 10

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Target population of Emirdag

• Poor
• Uneducated
• With no regular work and income
• Mostly without permanent house
• With high expectations of social solutions
• With problematic health services use

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ADEPSTEPYüksel, Sercan, Sezgin, Gökalp
2005PSYCHOLOGICAL SUPPORT, SCREENING AND
TREATMENT PROJECT FOR POST-DISASTER MENTAL HEALTH
PROBLEMS IN ADAPAZARI

• Objectives inadequate mental health services in
  the area.
• Supporting mental health facilities in the area
• Identifying risk groups for PTSD and other Axis I
  disorders (Screening the unselected traumatized
  population)
• Treatment and counselling
• Follow-up of those who need treatment for 1 year

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ADEPSTEP

• Project team 14 volunteer psychiatrists and
  psychologists from two institutions in Istanbul
• Support of NGO Adapazari Earthquake Survivors
  Organization
• Scientifically Supported by
• Psychiatric Association of Turkey
• ESTSS
• TMA
• Financially Supported by ACT Netherlands

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ADEPSTEP

• Screening and Evaluation Instruments
• Eartquake History Inventory (SezginYüksel, 2000)
• Posttraumatic Diagnosis Scale (Foa 1995 )
• Impact of Events Scale-R(Horowitz et al. 1979
  Marmar 1996)
• Diagnosis DSM-IV
• Follow-up Instruments
• CGI
• HRSD, HRSA

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ADEPSTEP

• The screening at 8th month after the
  earthquake.
• Those who were identified at risk were
  interviewed again by a mental health professional
  for diagnostic purposes and treatment.
• Those who needed medication were followed up for
  medication. Those who were included in group
  therapy had sessions every two weeks.

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ADEPSTEP

• 350 people were screened
• 71 (n247) were women
• 29 (n103) were men
• Age 37.45 (12.8) R16-80
• Low income
• Low-middle education status
• Married, with average 2 children
• Housewives (63.7)

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ADEPSTEPRisk Factors for PTSD

• Being rescued from the rubbles
• Being injured
• Having a close other died near her/himself
• Having a close relative who died in the
  earthquake
• Participating in rescue efforts

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ADEPSTEP

• 59.7 had PTSD
• Those with medium and serious symptom severity
  were 61.8
• Those with medium and serious functional
  impairment were 57.1 .

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Disaster mental health services in the
fieldhomework questions !

• Is research needed on disaster mental health ?
  Research is needed to understand the nature of
  the reactions to disaster and the efficacy of the
  interventions
• Did research emerge from these services?
• What happened to surveys on the first days of the
  disaster?
• What happened to unpublished data and information
  ?
• Who publishes the Experiences?
• WPA Disasters and Mental Health

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More Questions

• Are disaster survivors eligible for IC ?
• Is the decisional capacity of survivors impaired?
• Some survivors might have an impaired decisional
  capacity due to the effects of acute stress.
  Physical trauma, general medical instability
  might worsen the situation, but cannot be
  generalized (Rosenstein 2004).
• The method of assessment for decisional capacity
  should be stated (Yüksel 2005).

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Some More Questions !!

• Are disaster survivors a vulnerable population?
• No definite definition of vulnerability in
  medical ethics.
• Vulnerability increases if social status, sense
  of power, education level decrease.
• Helsinki Declaration some groups of people are
  more prone to be damaged from medical research,
  therefore these people deserve more protection
  and caution
• Disaster survivors might be more vulnerable in
  the acute phase.

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The ethical evaluation of ADEPSTEP I

• The survey was planned as a services project,
  focusing on the needs of the affected population.
• As stated in the Helsinki Declaration (WMA) a
  high risk disadvantaged group who had no other
  opportunity for treatment / professional help was
  selected.
• DEP-DER ( NGO formed by the earthquake survivors
  of the area) was included and consulted in every
  step of the project.
• The members of the staff were chosen from those
  who were experienced on trauma field work.
• Yüksel 2005 (in press)

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ADEPSTEP (ethics) II

• Subjects who volunteered after the introductory
  meeting and had full capacity for informed
  consent were included.
• Those included were given clear information on
  the process of interviewing and treatment
  options.
• It was observed that illiterate people were
  confused with signing IC forms and caused worry
  and suspicion.
• The subjects had the right to exclude themselves
  from the project at any step.

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ADEPSTEP (ethics) III

• The calls for interviews were made by DEP-DER
  which is an NGO with no relation with official
  authorities.
• Local resources were not used for any need of the
  staff or the project.
• The confidentialty issue was given utmost
  importance although there were practical
  difficulties. The charts were kept in Istanbul
  and carried for every visit.

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