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Public Health & Mental Health Preparedness for Mass Casualty,Public Health Emergency Preparedness: Tools for the FrontlineNorthwest Center for Public Health PracticeSchool of Public Health and Community MedicineUniversity of WashingtonAugust 3, 2004Marcus Nemuth, MDDirector, Psychiatry Emergency ServiceSeattle Veterans Administration Puget Sound Health Care SystemHead, VAPSHCS Mental Health Disaster Task ForceClinical Faculty, University of WashingtonFaculty, Northwest Center for Public Health Practice,Early Examples of Terrorism Greek Myth - Hercules dipped arrows in Hydra venom “Toxon” means arrow Alexander the Great - combustible toxins sulphur, quick lime, Naphtha Created terror in enemies Today - more sophisticated and powerful, ability to affect entire societies,Disaster in Developing Countries,Higher mean aggregate severityof MH impairmentPoorly studiedDeath tolls measured in tens of thousandsMexico City earthquake 85, Armero volcano eruption 85, Armenian earthquake 88, Hurricane Mitch 98Relief should match cultural context and needs of group Relevance for US in aftermath of enormity of 9/11,Review of Disaster Studies 1981-2001,160 Disaster SamplesMore than 60,000 individuals29 CountriesNatural,Technological, and Mass ViolenceOne-fifth of studies Very Severe impairment 50% rates of psychopathology Norris, Friedman, Watson Psychiatry 2002,Disaster Magnitude re: Population MH Effects,Greatest when at least 2 event -level factors:Extreme & widespread property damage, community disruptionSerious and ongoing community-wide financial problemsCaused by human intentHigh prevalence of trauma, injuries, threat to life, loss of lifeNorris 2002,Low Impact Disasters,Majority of individuals rebound, requiring no treatment Facilitated by social, educational and community wide supportive interventionsDuration of EffectsSymptoms peak in the first yearPatterns of decline are variableExample: Northridge Earthquake 94Symptoms of re experiencing and hyper arousal, but did not develop major psychiatric illnessMcMillen, 2000,High Impact Disasters,Oklahoma City Bombing 34% PTSD45% one or more psychiatric illnessMedian time to remission:with treatment 36 monthswithout treatment 64 months 1/3 victims have not remitted All survivors with blast-related acoustic deafness developed PTSD Kessler 1995North 2002,Disasters,Low impact Mt St Helens Eruption 80Loma Prieta Earthquake 89 SF World Series 62 deaths, 4,000 injuredNorthridge Earthquake 94Hurricane Isabel 03San Diego Fires 03Moderate impact 3 Mile Island Nuclear Accident 79, 600,000 affectedHurricane Hugo 89, Charleston, SC, 82 deathsHigh impact Buffalo Creek Dam Collapse 72, 125 killedBeverly Hills Supper Club Fire 77, 165 killedExxon Valdez Oil Spill 89, 11,000 clean-up workers made 6,000 medical visitsHurricane Andrew 92, PTSD 25%Oklahoma City Bombing 95, PTSD 34%,Terrorism: definition and examples,Illegal or threatened use of force or violence to coerce societies or governments by inducing fear in populations, involving ideological and political motives and justifications. National Research Council, 2002Damaging mental well-being is the exact purpose of terrorism.Examples in USA:2001 WTC and Pentagon AttacksFall 2001 Anthrax Attacks 1995 Oklahoma City Bombing,Terrorism targets community psyche as much as bodies and buildings,Psych sequelae - more serious, complex and long term, uncertainty and vulnerabilityDifficult to assimilate manmade violence, intrusion and avoidance symptoms more likelyMore organizationally complex, more agencies, criminal aspect of eventRescuers - stress by long exposure to scene, experiences different from natural disasters, risk of contamination,Terrorism vs. Natural Disasters,Survey Results,“Public Perspectives MH Effects of Terrorism” Poll61% fear terrorism more than natural disaster77% believe info on strategies to cope with fear and distress needed, equal importance to securing physical installations57% do not think the PH system is meeting the MH needs resulting from the threat of terrorism Information received after a crisis significantly shapes reactions over the weeks and years following,NASMHPD, NMHA and Consortium for Risk and Crisis Communications, 2004,Madird March 11, 2004 NYC September 11, 2001,Madrid March 11, 2004,Madrid March 11, 2004,Madrid March 11, 2004,Immediate Reactions,DisbeliefDisorientationFearFeeling time is slowed downFeeling numb or disconnectedFeeling helpless or irrationally failing to avoid danger,MH Plan for Intervention Assist With: Physical Needs,Establish safety, medical, food, water, shelter, communication to public regarding event and future risks A good crisis management MH worker can:“Cook a meal, empty the garbage, make coffee, change a bed, file, type, sort papers, answer phones, drive a van, stock supplies, put up a tent, operate a radio, mark a trail, cut wood, baby-sit, and fold clothes, in addition to his/her MH role” Institute of Medicine 2002,Madrid March 11, 2004,201 people killed, 1600 injuredTaken to 5 hospitalsHospital Gregorio Maranon - 350 patients in 1 hour usually 300 patients / dayAlfredo Calcedo Barba, Profesor de Psiquiatria, Universidad ComplutenseVictim identification obstaclesNames of patients could not be registeredRelatives overwhelmed the ERArguments between relatives and hospital staff Corpses disfigured, ID impossible, DNA testingMiscommunication to families,Madrid MH Response,Crisis intervention team set up to support Consult Liaison Unit40 MHPs attended medical, surgical, and pediatric wards within 24 hoursUnidentified bodies taken to a trade pavilion1,000 MHPs volunteered to support families Families were always accompaniedOutpatient MH clinics beginning to receive firemen and other EMS workers for counseling,Early Responses to 9/11 AttacksNationwide 1 week,44% adults - 1 or more substantial stress symptoms35% children - 1 or more substantial stress symptoms intrusive thoughts “very upset” when reminded nightmares, sleep disturbance poor concentration anger outburstsSchuster NEJ Nov 01 N = 768 telephone survey,Early Responses to 9/11 AttacksNationwide 1week,20% of Americans know someone who was missing, hurt or killed64% had a shaken sense of safety & security43% less willing to travel by airplanePositive Adaptation growth, altruism, activism, creativity, empathyAmerican Psychological Assn Feb 2002 Gallup 2001,Response to 9/11 AttacksManhattan South of 110th St 1 - 2 months,7.5%New onset PTSD related to 9/11(67,000)9.7%New onset Depressionsince 9/11(87,000)20% PTSD below Canal Street, near WTC Galea, 2002 NYAM N = 1008 N = 2001 N = 2752,Longitudinal National Study - Reactions to 9/11,USA Metro/Rural: 9/11 related PTSD symptoms, avg 5 pos Before attacks 2 % 2 months 17 %6 months 5.8% Silver, JAMA 2002 N = 4449 Secondary trauma via TV and other media correlated to PTSD symptoms, 60% witnessed via live TV. Pfefferbaum 2003; Rushing & John-Baptiste 2003Active coping in immediate aftermath was protective Silver, JAMA 2002Disengaging from active coping increased traumatic effect as in Breast CA, Prostate CA, HIV+ Perczek 2002, Cancer,NYC adult population = 6,068,009,represents approximately 51,000 people,Galea Nov 2003,Residents directly vs not directly affected by September 11 attacks,represents approximately 51,000 people,directly affected by September 11 attacks,not directly affected by September 11 attacks,Galea Nov 2003,PTSD 6 months after September 11,directly affected by September 11 attacks,not directly affected by September 11 attacks,PTSD since September 11,Galea Nov 2003,Effects of Mass Casualty,PTSD, Major Depressive Disorder, Generalized Anxiety D/O, Panic D/ONonspecific distress Health problems / concernsChronic problems in livingPsychosocial resource loss social support, self efficacy, optimism, perceived controlPositive Adaptationgrowth, altruism, activism, creativity, empathyNorris 2002,Project Liberty - NYC,FEMA, ARC, NYC Dept MH, Crisis Counseling Assistance/Training Program CCP federal Center for MH Services CMHS $150 million Trained 4,500 crisis counselors to provide 4 step responseServed over 1 million people in 37 languages, distributed 20 million brochures,Mass Casualty / Terrorism Psycho-Social Fallout Therapeutic Interventions,Functions to Protect and Respond to Public Psychological Health,Basic resources food, shelter, communication, transportation, and medical servicesInterventions and programs to promote individual and community resilience Surveillance for psychological consequences Screening criteria for individualsTreatment for acute and long-term effects of the trauma,Functions to Protect and Respond to Public Psychological Health,Human Services - contribute to psychological functioning, reuniting families, child care, housing, job assistanceRisk Communication, dissemination of informationTraining of service providers to respond. Prepare and protect them against psychological traumaCapacity to handle large increase in demand for services - “Surge Capacity”Case finding to locate individuals who need MH services but are not utilizing conventional means; including the underserved, marginalized, and unrecognized groups of people,Identify MH Risk,“Normal Response” still had disability, maladaptation, suicidalityRandall Marshall survey 2001Symptoms sub-threshold to DSM diagnosis receive little attentionAside from Panic and Disassociative states, psychological reactions tend to be time-delayedProphylactic tx after trauma may limit PTSDYehuda 2004,Vulnerable Populations,Predictors of psychological distress post terrorist event:Consequences are related to the quality and extent of exposure - being a victim, watching the attacks, talking on the phone with someone who was lost Silver 2002; Schlenger 2002Female gender is associated with worse short-term outcomes Silver 2002Weak or deteriorating psychosocial resources Norris et al, 2002Those with pre existing physical illness Shlev 2001 or mental Illness Yehuda 2002,Vulnerable Populations continued,Predictors of psychological distress post terrorist event:Prior exposure to violence and trauma (Veterans) Hoven 2002Hispanics and other immigrant populations, including refugees Galea et al. 2002School aged childrenPfefferbaum 2003Middle aged and young adults are at greater risk than older adults (contrary to popular belief)First responders - unique exposure & risk Beaton & Nemuth, J Traumatology 2004,Individual-Level Risk Factors for Poor MH Outcomes:,Trauma/StressSevere exposure, injury, threat to life, extreme loss, disrupted community, high secondary stressCharacteristics Female gender, age 40-60, no experience in coping techniques,ethnic minority, low SES, prior psych hxFamily ContextAdults with children, female with spouse, child with dysfunctional parentResource ContextLow belief in ability to control outcomes deteriorating social resources Norris 2002,Children / Youth,8300 students grades 4-12, screened in NYC public schools Feb and Mar 2002 27% met diagnostic criteria (3 x baseline)PTSD, Agoraphobia, Panic d/o, Conduct d/o, Depression, GAD Christina Hoven, Columbia 2002Age specific problems hyperactivity, delinquencyLess well equipped to copeUnique understanding of event meaningPfefferbaum 2001; Norris 2002; Tenhundfeld 2003,First RespondersPhysical danger (firefighters, police, uniformed personnel) Beaton & Nemuth, Secondary Traumatic Stress in Firefighters, 2004Horror and the dead (medical personnel, body handlers)11 months after 9/11, NYFD rescue workers had 17 fold increase in stress related incidents compared to 11 months prior to the attack Banauch 2002Resilience: capacity for peer support, develop a meaningful narrative about events Norris 2002,NYFD & Emergency Medical Service Workers,9/11Firefighters and EMS workers = 14,000 treated by counseling unitAvg caseload prior 9/11 = 600, now 3,600 in every Dx categoryAnxiety DO, PTSD, Bereavement ETOH / Substance Abuse 50% in 1 year (2X national average, Cornell Univ) March, 2004,NYFD & Emergency Medical Service Workers,Working at WTC after attack appears associated with delayed symptomsJuly 2002 WTC site closed, # cases presenting dramatically PTSD - almost all have been delayed in onset risk taking behavior while on duty, especially in unit with high # losses in 9/11Researchers now looking at correlations March, 2004,Increased substance use in Manhattan after September 11,Vlahov et al. Am J Pub Health. 2004; In press,PTSD in Severely Mentally Ill,Higher rates in: Young White Homeless UnemployedMore common with hx of: Major mood disorders Medical ills / high primary care utilization Recent psychiatric hospitalizationConsequences for Severely Mentally Ill: Increased - medical comorbidity use of health services and MH services substance abuse alcohol use global level of social dysfunction,Muesser KT, et al 2004,Trauma Exposure & Physical Health,Medically Unexplained Physical Symptoms - MUPSSelf reported symptom complaints Ground Zero syndrome / respiratoryPhysician reported diagnoses Abnormal Laboratory testsLow birth weight infantsMortality ( cardiac)Loss of routine medical care: home health care, O2, meds, chemo, chronic medical conditions worsenedAu der Heide 2002Green & Kimerling (in press)Schnurr & Jankowski, 1999Sabatino, JAHA 1992,Early Intervention to Reduce:,Acute Stress Disorder ASDPost Traumatic Stress Disorder PTSDDepression Sleep Disturbances Panic Disorder Physiological arousalSubstance Use Disorders Anxiety / FearPhysical Health problems Functional disabilityUnexplained somatic symptoms Complicated bereavement reactionsAnger dyscontrol / Family violenceRegression of childhood developmental progressionWatson 2003Ursano 2003,Therapeutic Interventions,Psycho education Anxiety managementSupportive TherapyCognitive Behavioral Therapy CBTCritical Incident Stress Management CISMPharmacological intervention for acute stress management, depression,MH Screening,PTSD more likely when: Panic attacks during / shortly after terrorist event measured by elevated heart rate and low cortisol level Shalev 1992, Tucker/Pfefferbaum 2000, Yehuda 2002Depression more likely when: Panic attacks, job loss, death of friend or relative Decrease in social support in prior 6 monthsUse data to provide early and better careCaution and sensitivity are critical in screening to avoid pathologizing Impact Event Scale Revised IES-R Stanford Acute Stress D/O Questionnaire SASRQ,Critical Incident Stress Debriefing,Emotional processing through discussion of the experience, grief model Normalization of stress reactionsMultiple Reviews: Rose, Cochran Review 2001; Van Emmerik, Lancet 2002; Everly, Psychiatric Quarterly 2002; McNally APS 2003Debriefing is ineffective and can be harmful RetraumatizationConfounds:Not operationally definedOne on One vs Group debriefingMandated vs VoluntaryNo RCTs conducted with mass violence populations,Critical Incident Stress Management CISM,Pre Crisis trainingInformational briefings, “town meetings”“Defusing”One on One and Family crisis counselingScreening and treatment referral mechanismCISM used by Uniformed Services (DoD, Fire, Police),Cognitive Behavioral Techniques CBT,Strongest empirical results4 of 5 RCTs found clear superiority of CBT vs supportive counseling or controls Bryant in press, Ehlers Biol Psy 2003, Foa 1995 4 5 sessions, psychoeducation, anxiety management, cognitive restructuring, exposure NCPTSDExposure techniques may be contraindicated in early phases, other CB techniques may be effectiveEMDR - no RCTs demonstrated effectiveness within 4 weeks of exposure NCPTSD,Pharmacotherapy,Imipramine: low dose significant reduction in ASD symptoms Robert 1999Propanolol: reduction in conditioned response to trauma stimuli Pitman 2002Prazosin: reduction in nightmares Raskind 2002Benzodiazepines: widely used after 9/11 for anxiety No evidence of PTSD protective benefitSSRIs: first line drugs for PTSDRisperidone: 5 days post-trauma associated with decreased sleep disturba