Research in Deployment Health and Stressrelated Disorders

1
Research in Deployment Health and Stress-related
Disorders

• Joseph I. Constans, Ph.D.
• South Central MIRECC
• 2006 Retreat

2
Goals

• Review (quickly) current projects
• plug for Research Rounds
• Discuss Hurricane Study

3
Current Projects of MIRECC Investigators

• Predicting PTSD Outcomes Using Objective
  Psychophysiologic Measures (Jeff Pyne - PI)
• Use of VR, cognitive, psychophysiological
  paradigms
• VA/NIH support
• Predicting PTSD course with non self-report based
  assessments
• Arkansas National Guard
• Bring VR technology to LR for treatment
• Couples therapy for veterans with PTSD (Sautter
  PI)
• R21 submission
• Collaboration between clinical / research teams

4
Current Projects of MIRECC Investigators

• Cognitive Training Programs in the Treatment of
  Stress-Related Emotional Disorders (Constans -
  PI)
• VA Merit Review
• using computer-based training programs
• allows for increased practice in changing
  pathological cognitions associated with
  depression and PTSD.
• augment current therapies improve access to
  care?????
• Treatment of co-morbid anxiety disorders in PTSD
  (Teng, Dunn, Bailey)
• Panic control therapy
• MIRECC support

5
Impact of Hurricane Katrina on Gulf Coast
veterans with and without pre-existing mental
illness.

• Principal Investigator Joseph Constans, Ph.D.
• Co-Investigators
• Greer Sullivan, M.D.
• Jennifer Vasterling, Ph.D.
• Project Director Elizabeth Deitch, Ph.D.
• VA Database managers
• Teresa Hudson, Ph.D.
• Mark Austen
• Survey Development and Administration Consultant
  
• Dana Perry, M.S.

6
Hurricane Katrina

• The costliest one of the most destructive
  hurricanes in U.S. history.
• Massive size devastated Gulf Coast up to 100
  miles from storm center.
• Over half of New Orleans flooded when levees
  breached.
• A number of Mississippi Gulf Coast communities
  were wiped out.
• Approximately 1720 people died in storm and
  aftermath.

7
Immediate Stressors related to Hurricane Katrina

• Fear for life of self others
• From storm itself, floodwaters, hunger, thirst
• Fear of crime and violence
• Looting, assaults, breakdowns of civil authority
• Breakdown of civil authority
• Exposure to bodies / potential contaminates
• Uncertainty Ambiguity
• N.O. evacuation stretched to a month status of
  homes, jobs, friends/family/pets uncertain.

8
Prolonged Stressors related to Hurricane Katrina

• Loss of housing
• Temporary housing in trailers
• Permanent move
• Loss of employment / income
• Loss of belongings
• Furniture, sentimental items
• Loss of support system
• Neighborhoods families split up
• Increased incidence of divorce

9
Impact of Natural Disasterson Health

• Increased general distress
• Lasting 30 months
• Increased incidence of psychiatric disturbance
• PTSD (31)
• Depression (30)
• GAD (11)
• Panic disorder (10)
• Hurricane Andrew estimates (Davis et al., 1996)
• Poorer physical health outcomes
• Lower immune function
• Impaired sleep

10
Risk factors for Poor Health Outcomes

• Severity of natural disaster
• Similar to relationship between combat /
  emotional disorders
• Severe disasters more trauma more loss
• Poor social support
• Katrina led to disruption of neighborhood
  networks, churches, social organizations
• Ethnic minority status
• New Orleans 73 African-American
• Lower SES
• 23 NO residents below poverty line
• Pre-existing mental illness
• Mostly using retrospective assessment
• Prospective studies emphasized depression
• Role of PTSD / Schizophrenia ????
• Unclear how pre-existing mental illness interacts
  with other risk factors

11
Reactions to Katrina

• Diaspora challenges for researchers.
• Eliminates face-to-face contact (Norris et al.)
• Changes in contact information
• Kessler, Galea, Jones, Parker (2006)
• Use of cell phones for contacting residents
• Access to mental disorder incidence prior to
  storm
• Documented increases in mental disorders
• Found suicidal ideation did not increase
  proportionately
• Beliefs in post traumatic growth important
  moderator

12
Examining impact of Katrina on Gulf Coast
veterans

• What is the health impact on veterans?
• What is the specific impact on veterans with
  psychiatric disturbances such as PTSD/
  schizophrenia?
• Use of VA databases to identify /- for
  pre-existing mental illness
• Allows for a prospective assessment
• Allows to assess possibly unique features of PTSD
  / schizophrenia
• Examine fit of current risk models
• Does psychiatric status impact other risk
  factors?

13
Current Study Aims (1)

• Pre-existing mental illness (PMI) is a risk
  factor for developing new-onset disorders after
  natural disaster (Norris Elrod, 2006).
• Veterans have not been specifically studied.
• It is unclear how veterans, especially those with
  combat stress, will react to disasters.
• Hypothesis 1 Veterans with PMI will show
  significantly higher rates of new-onset post-
  traumatic stress disorder (PTSD), major
  depressive disorder (MDD), panic disorder (PD),
  and generalized anxiety disorder (GAD) after
  Hurricane Katrina, as compared with veterans
  without evidence of PMI.

14
Current Study Aims (2)

• Other risk factors for post-disaster mental
  illness include lack of social support negative
  cognitive appraisals (see review by Norris et al,
  2002)
• PMI may be associated with these risk factors,
  contributing to negative outcomes.
• Hypothesis 2a Veterans with PMI before Katrina
  will report lower levels of social support than
  veterans without PMI.
• Hypothesis 2b Veterans with PMI will engage in
  more negative cognitive appraisals of the impact
  of the hurricane and their actions and emotions
  in response to it, than will veterans without PMI.

15
Current Study Aims (3)

• Study includes exploratory investigation of
  relative impact of various risk factors, and
  whether risks are similar for those with and
  without PMI.
• Predictors of interest include
• Severity of exposure to hurricane stressors
• Severity of ongoing stressors
• Social support
• Cognitive appraisals
• Financial resources

16
Overview of Study Design

• Telephone survey
• experiences during after Katrina
• Loss, social support, cognitive factors
• Current health / mental health functioning
• Administered by professional survey firm.
• 500 participants
• 250 with pre-existing mental illness
• 250 with no PMI.

17
Participants

• 500 male veterans aged 18-60 as of 8/29/05
• Received services at N.O. or Biloxi VAMC.
• Resided in affected area at time of Katrina
• LA parishes Jefferson, Orleans, Plaquemines, St.
  Tammany, St. Bernard
• MS counties Hancock, Harrison, Jackson
• MI positive cohort (n250)
• 2 visits to mental health clinic between
  8/1/04-8/1/05
• Diagnosis of depression, PTSD, or psychotic
  disorder
• MI negative cohort (n250)
• 2 visits to primary care clinic between
  8/1/04-8/1/05
• No mental illness diagnoses

18
Survey Measures

• Demographic Information
• Age, sex, ethnicity, marital status, education
• Employment/Income
• Status at time of Katrina, current status,
  changes
• Military History
• Service branch, combat zone experience
• Household Information
• Living situation pre-K and now (location,
  structure, household members) extent of damage
  to home/possessions

19
Survey Measures (contd)

• Katrina trauma severity
• Emotional events experienced (e.g., witnessing
  deaths, loss of friends/family/pets in storm
• Other traumas during storm aftermath (e.g.,
  assault, robbery)
• Cognitive appraisals
• Posttraumatic Cognitions Inventory (Foa, Clark,
  Tolin Orsillo, 1999)
• Posttraumatic growth (Kessler, Galea et al.,
  2006)

20
Survey Measures (contd)

• Traumatic life events
• Checklist of lifetime traumatic events other than
  Katrina (e.g., serious accident, assault).
• Modified version of Diagnostic Interview Schedule
  (CDC, 1989)
• Post-traumatic stress disorder
• Short PTSD Rating Interview (SPRINT Connor
  Davidson, 2001)
• Generalized Anxiety Disorder
• GAD-7 (Spitzer, Kroenke, Williams, Lowe, 2006)
  assesses frequency of anxiety symptoms

21
Survey Measures (contd)

• Panic disorder
• PD screen from Brief Patient Health
  Question-naire (Spitzer, Kroenke Williams,
  1999)
• Depression
• 2-item screen from Patient Health Questionnaire
  (PHQ-2 Kroenke , Spitzer Williams, 2003)
• Anger
• Anger subscale of the Buss-Perry Aggression scale
  (Buss Perry, 1992)

22
Survey Measures (contd)

• Perceived Social Support
• 3 items each for emotional support, tangible
  support, informational support.
• scale constructed by Norris Kaniasty (1996)
  from items from the Interpersonal Support
  Evalu-ation List (Cohen Hoberman, 1983) and
  Social Provisions Scale (Cutrona Russell, 1987)
• Alcohol Use
• 3 items from Alcohol Use Disorders Identification
  Test (Babor, de la Fuente, Saunders Grant,1989)
• Also, compare consumption pre- post-Katrina

23
Survey Measures (contd)

• Physical Health
• 9-item checklist for specific health problems
  (e.g., diabetes, cancer)
• 16-item measure for respondent evaluation of
  state of health some original items and some
  from SF-12 Health Survey (Ware, Kosinski
  Keller, 1996)

24
Procedure Participant Identification

• Using info from VA data warehouse
• 250 MI veterans will be randomly selected.
• PTSD, depression, psychotic disorder
• 250 MI- veterans
• Groups match MI cohort on age, ethnicity, zip
  code at time of Katrina, number of clinic visits.
• Names contact info supplied to survey
  administration firm.

25
Procedure Contact Protocol

• Pre-notification letter sent to potential
  participants, allows opt-out by postcard or phone
  (wait 3-4 weeks).
• Interviewer will call, explain study, answer
  questions, obtain verbal informed consent.
• Survey will be administered as telephone
  interview (about 1 hour long).
• Address will be recorded to mail 20 compensation
  check.

26
Procedure Follow-Up Location

• For veterans
• Undeliverable mail
• Invalid phone numbers
• Use of locator service (possibly using SSN).
• Second iteration of identification/enrollment
• Generate list of names for 120 of remaining
  veterans needed to reach n250 for each group.
• Follow contact protocol
• Repeat if necessary

27
Challenges VA Privacy/Security Issues

• New VA security directives Implications for use
  of private survey administration firms.
• New requirements for storing any identified data
  anywhere outside the VA (e.g., that equipment is
  FISMA certified)
• Although survey data will be identified by a code
  number, not name, it will contain zip code
  information and so is not considered
  de-identified.
• Veterans names, addresses and SSNs may reside
  only on VA servers.

28
Privacy/Security Issues

• Potential solution in consultation with ISO, set
  up a Virtual Private Network (VPN) for the
  survey/locator company.
• Would give company limited access to a shared VA
  server where needed veterans info is stored.
• Survey data and address for compensation would be
  entered directly onto the VA server via the VPN.
• Would probably require that all users of the VPN
  complete VHA Privacy Policy Training and Cyber
  Security Awareness Training.

29
Conclusion

• VA database provides information allowing for
  prospective design with regard to studying impact
  of disasters on those with prior mental illness.
• Significant challenges to accessing information
  in VA databases.
• Study will be first specifically investigating
  impact of disaster on veteran population.