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

Acute Post disaster Rescue PhaseAcute Post disaster Rescue Phase

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

Medium term recovery phaseMedium term recovery phase

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

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

Prevalence of PTSD after a mass traumatic Prevalence of PTSD after a mass traumatic eventevent

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

Black Saturday Black Saturday

77thth February 2009 February 2009

Impact of Change of Wind Impact of Change of Wind DirectionDirection

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

Thank youThank you

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 alexander.mcfarlane@adelaide.edu.auEmail alexander.mcfarlane@adelaide.edu.au