The Role Consultation Liaison Services when Disaster Strikes

1
The Role Consultation Liaison Services when
Disaster Strikes

• A C McFarlane AO
• Professor of Psychiatry
• Centre for Traumatic Stress Studies
• The University of Adelaide

2
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

3
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 Xiaopings
  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

4
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

5
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.

6
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

7
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.

8
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

9
Acute Post disaster Rescue Phase
10
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

11
Debriefing

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

12
Time Frames of Service Demand
Medical Services Rehab Treatment Psychiatry Services
ACUTE/ RESCUE -
MEDIUM/ RECOVERY
CHRONIC/ RESTORATN -
13
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

14
Medium term recovery phase
15
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

16
Saw doctor about physical health complaint

• PTSD No PTSD (n 77) (n
  70)Respiratory 19 4 6.69
• Musculoskeletal 39 22 4.00
• Cardiovascular 14 9 0.52
• Gastrointestinal 13 6 1.06
• Dermatological 17 9 1.46
• Urological 1 4 0.16
• Headaches funny turns 17 9 1.45
• Plt0.05 Plt0.01

17
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

18
Chronic posttraumatic re-establishment phase
19
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

20
Identification of Post Disaster Morbidity
SUBCLINICAL
UNKNOWN DISORDER
KNOWN DISORDER
TOTAL DISASTER POPULATION
21
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

22
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

23
The issue of the pattern of onset PTSD

• Severe acute distress is the exception and
  progressive increase of symptoms is very common

24
Percentage of psychiatric cases in children after
a bushfire
25
Prevalence of PTSD after a mass traumatic event
26
Trajectory of PTS symptoms, with probabilities
8.5
7.6
6.7
10.9
19.4
6.2
40.7
Norris FH, Tracy M, Galea S. Psychological
resilience as a trajectory Evidence from two
major disasters. Social Science Medicine. In
Press.
27
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

28
Progression of cases at 24 months in accident and
work injuries n96

• 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

29
60 Month Follow Up
Chronic 4.0
Delayed onset 9.6
Delayed onset (resolving) 8.1
Acute resolving 5.7
No symptoms 72.5
30
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

31
The issue of delayed onset PTSD

• Severe acute distress is the exception and
  progressive increase of symptoms is very common

32
Posttraumatic Sensitization Disorder

• The risk of PTSD following first exposures is
  less than later exposures

33
Do not forget the background psychiatric
morbidity of the population
34
Post Disaster Morbidity
Total Population
Other Psychiatric Disorder
PTSD
Traumatic Event
35
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

36
GHQ cases 5 months after Yunnan Earthquake
Control n908 Disaster group n1294
37
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

38
Disasters vs 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
39
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

40
Design type by year The proportion of
longitudinal studies has been decreasing
Norris 2006
41
Black Saturday

• 7th February 2009

42
Impact of Change of Wind Direction
43
Similarity of Weather Systems

• Ash Wednesday

• Black Saturday

44
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45
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

46
Ash Wednesday Disaster

• 75 people killed
• 2676 injured
• Over 3700 buildings destroyed
• 1,032,000 acres burnt

47
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

48
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

49
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

50
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

51
Thank you
52
Prof AC McFarlane

• Centre of Military and Veterans Health
• The University of Adelaide
• 122 Frome Street
• Adelaide
• South Australia
• Australia 5000
• Telephone [phone]
• Fax [phone]
• Email alexander.mcfarlane_at_adelaide.edu.au