psychiatric illness identification & treatment for mass ......and first responders . october...

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Psychiatric Illness Identification and Treatment for Mass Casualty Event Survivors

and First Responders

October 2018 MRC2.CORP.D.00377


Speaker Profiles

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Richard Weisler, MDPosition: Richard Weisler, MD, has had a psychiatric practice since 1980, where he and his team follow more than 2,000 patients with a mixture of psychiatric disorders. He is board certified by the American Board of Psychiatry and Neurology. He is an Adjunct Professor of Psychiatry at the University of North Carolina (UNC) Chapel Hill School of Medicine, where he has also served for many years as chairman of the Board of Visitors for the Department of Psychiatry. Dr. Weisler is also Adjunct Associate Professor of Psychiatry & Behavioral Sciences at Duke University Medical Center.

Education: Dr. Weisler received his MD from the University of North Carolina at Chapel Hill.

Allan Chrisman, MDPosition: Allan Chrisman, MD, is an Associate Professor Emeritus at Duke University School of Medicine. During his 40 years of practice in general adult and child psychiatry, he worked on inpatient, residential and outpatient settings. He practiced for 13 ½ years of practice at an HMO, the Harvard Community Health Plan where he was a consultant to pediatric and internal medicine practices. He also was chief of two mental health departments at the Harvard Community Health Plan- Cambridge and Watertown, MA. Since retiring, he has pursued his interest in disaster mental health as an American Red Cross Disaster Health Services and Disaster Mental Health volunteer during disasters.

Education: Dr. Chrisman received his MD from the George Washington University School of Medicine

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Speakers are paid consultants for Otsuka Pharmaceutical Development & Commercialization, Inc.



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Defining Human-Made Disaster


What is a Human-Made Disaster?

• Causations include evil human intent, deliberate sociopolitical act, human cruelty, revenge, hate or bias against a group, mental illness1

– Event seems incomprehensible, senseless– Some view as uncontrollable and unpredictable, others view as

preventable– Social order has been violated

• Examples2:

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1. U.S. Department of Health and Human Services. Mental Health Response to Mass Violence and Terrorism: A Training Manual. DHHS Pub. No. SMA 3959. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2004.

2. World Health Organization. Division of Mental Health. Psychosocial consequences of disasters: prevention and management. Geneva, Switzerland: World Health Organization; 1992. http://apps.who.int/iris/bitstream/handle/10665/58986/WHO_MNH_PSF_91.3_REV.1.pdf?sequence=1&isAllowed=y. Accessed July 10, 2018.

• Nuclear • Explosions

• Chemical • Transport Accidents• Biological • Toxic


Who Causes Human-Made Disasters?1

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1. Akhtar S. Psychiatric Annals, 1999:29(6):350-355.

Experienced abuse/ emotional humiliation

Has an idealized vision of what should be

Destruction of society is seen as a necessary means to achieve their

goals

• Deep mistrust of others• Hatred/ violent tendencies

toward others

• Malignant narcissism• Turns passivity/

masochism/ victimization into activity/ sadism/ victimizer

• Amoral in the service of their goals

• Little empathy for those who stand in the way


Psychological Response to a Human-Made Disaster


Psychological Impact of Human-Made Disasters1

• Life threat, mass casualties, exposure to trauma, and prolonged recovery effect result in significant physical and emotional effects

• Subjective Experience– May experience terror, fear, sense of betrayal and violation– Resulting distrust, fear of people, or being “out of the world” may cause

withdrawal and isolation– Outrage, blaming the individual or group responsible, desire for revenge,

and demand for justice

• Compared to natural disasters, prevalence and duration of PTSD in human-made disasters is often higher and longer– Rates range from 2.3% to 17%2

– General decline in the prevalence of PTSD over time2

• Preliminary evidence that impact of the trauma among high-risk groups may endure

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1. U.S. Department of Health and Human Services. Mental Health Response to Mass Violence and Terrorism: A Training Manual. DHHS Pub. No. SMA 3959. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2004

2. Neria Y et al., Psychol Med. 2008;38(4):467-480.

PTSD = Post-traumatic Stress Disorder


Physiological Effects of Human-Made Disasters

• After a human-made disaster the contribution of the psychological factors to medical illness can be pervasive1: – Cardiovascular

• Hypertension2

• Acute coronary syndrome3

– Respiratory• Chronic obstructive pulmonary disease (COPD)2

• Lower respiratory symptoms (LRS)3

• Asthma2

– Fatigue4

– Sleep apnea2

– Off-spring born shortly after event have lower birth weight5

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1. D’Andrea W et al., Journal of the American Psychiatric Nurses Association, 2011;17(6):378-392. 2. Bello GA et al., American Journal of Industrial Medicine, 2018;61:63-76. 3. Kotov R et al., Psychosomatic Medicine, 2015;77:438-448. 4. Kawana N et al., Military Medicine, 2001;166(2)::23-26. 5. Camacho A. American Economic Review, 2008;98(2):511-515.


Post-bombing Mental Health Outcomes1

• 167 casualties; assessed 182 of the 255 adult survivors– 45% had postdisaster psychiatric

disorder• 34.3% PTSD

– 76% reporting same-day onset– 94% meeting avoidance and

numbing criteria• 22.5% major depression• 4.4% generalized anxiety disorder

– Predictors• Disaster exposure• Female Sex (55% vs. 34%)• Predisaster psychiatric disorder

Murrah Building/ Oklahoma Bombing (April 19, 1995)

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1 North CS et al. JAMA, 1999;282:755-762.

PTSD = Post-traumatic stress disorder


Post-shooting Mental Health Outcomes1

• 49 students and faculty were shot, of whom 32 were killed

• Cross-sectional survey (n = 4,639) conducted with Virginia Tech students the following summer/fall:– High levels of posttraumatic stress

symptoms (probable PTSD) were experienced by 15.4% of respondents 3-4 months post-shooting

– Exposure that explained most of the cases of high posttraumatic stress symptoms were:

• 30.7% inability to confirm the safety of friends

• 20.3% death of a (not close) friend• 10.1% death of a close friend

Virginia Tech Shooting(April 16, 2007)

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1 Hughes M et al. Psychological Trauma: Theory, Research, Practice, and Policy, 2011;3(4),403.



Post-9/11 Mental Health Outcomes1

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• Approximately 3000 people were killed• Survey of adults (n = 1008), 5-8 weeks

post-9/11– 7.5% symptoms consistent with PTSD

• Predictors:– Hispanic– Two or more prior stressors– Panic attack during or shortly after the

events– Residence south of Canal Street– Loss of possessions due to the events

– 9.7% symptoms consistent with depression

• Predictors: – Hispanic ethnicity– Low level of social support– Death of a friend or relative during the

attacks– Loss of a job due to the attacks

1. Galea S et al. New England Journal of Medicine. 2003; 346(13):982-987.



Distress after Human-Made Disasters

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1. DeLisi LE et al., American Journal of Psychiatry, 2003; 160: 780-783. 2. Littleton HL et al., Psychological Trauma:Theory, Research, Practice, and Policy, 2009;1(3):206-219.3. Littleton H et al. Anxiety Stress Coping, 2011;24(3),273-290.

• 56.3% at least one severe or ≥ 2 mild to moderate symptoms• 27% sought treatment

• 29% employment changed• 10.5% lost close family member or friend• 33% painful memories associated with traumatic reminders

Survey 3-6 months post-9/11 (N = 1009)

• 193 undergraduate Virginia Tech women2

– Resource loss predicted greater psychological distress 6 months after the shooting– Social support and psychological distress prior to the shooting predicted resource loss– Social support and active coping with the shooting predicted resource gain

• 368 college women exposed to the mass shooting at Virginia Tech3

– Reciprocal relationship between maladaptive coping and general psychological distress over time.

– PTSD symptoms predicted coping over time PTSD = Post-traumatic stress disorder


Post-disaster Mental Health Outcomes of Rescue Workers

• Prevalence of PTSD among first responders assessed following involvement in rescue, recovery and cleaning efforts were especially high1

– 22.5% and 20% of disaster workers were found to suffer from PTSD at 2 weeks and 10-15 months after 9/11

• 181 male firefighters who served as rescue/recovery workers after the Oklahoma City bombing were assessed 34 months after the disaster2

– Significantly lower rates of PTSD (13% rescue workers vs. 25% primary victims) and panic disorder (1% rescue workers vs. 6% primary victims)

– Rate of alcohol use disorder was significantly higher (25% rescue workers vs. 10% primary victims)

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1. Neria Y et al., Psychol Med. 2008;38(4):467-480.2. North CS et al. American Journal of Psychiatry, 2002; 159:857-859.



Treatment Considerations after Human-Made Disaster


Phases of Disaster-Related Behaviors1

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1. Cohen R et al. Human problems in major disasters: a training curriculum for emergency medical personnel. Washington, D.C.; Government Printing Office; 1987.

The First Week

• Shock• Disbelief• Numbness• Denial• Somatic ills• Hyperarousal• Fear• Anxiety• Insomnia• Dysphoria

1-12 Weeks

• Increasing group solidarity

• Patriotism • Awareness of loss

and threat• Anger/ revenge• Mobilization• Suspiciousness• Stress related

emotional/ behavioral problems

12-52 Weeks

• Increasing disillusionment/ fear

• Embitterment by threats/ losses

• Loss/ fragmentation of community

• Individualism• Loss of idealism• Doubts regarding

leaders

1-5 Years

• Gradual acceptance of new reality

• Reappraisal of event and personal role

• Rebuilding of the community

• Struggles to adapt to: PTSD, loss, anxiety/dysphoria, somatic ills

• Changes attitudes: self/others/future



Complicated Grief1,2

• Define– Condition marked by symptoms of continuing separation distress

and accompanying bereavement-related traumatic distress

• Prevalence– Of 149 crisis counseling recipients (interviewed 1.5 years after

9/11), approximately half knew someone who had been killed in the attacks of which 44% screened positive for complicated grief1

– Viewing 9/11 live on television was strongly associated with complicated grief (47%)2

• Associated with:– Functional impairment– Suicide ideation– Higher utilization of mental health services

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1. Shear KM et al. Psychiatric Services, 2006;57:1291-1297.2. Neria Y et al. Journal of Traumatic Stress, 2007;20(3):251-262.


Differences between Complicated Grief and DSM-IV Disorders1

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1. Shear K et al. Journal American Medical Association, 2005; 293(21):2601-2608.

Major Depression

• Pervasive sad mood• Loss of Interest or pleasure• Pervasive sense of guilt• Rumination about past failures or

misdeeds

Posttraumatic Stress Disorder• Triggered by physical threat• Primary emotion is negative• Nightmares are very common• Painful reminders linked to the

traumatic event

Complicated Grief• Sadness related to missing the deceased• Interest in memories of the deceased

maintained; longing and yearning for contact• Guilt focused on interactions with the

deceased• Intrusive images of the person dying• Avoidance of situations and people related to

reminders of the loss

Complicated Grief• Triggered by loss• Primary emotion is sadness• Nightmares are rare• Painful reminders more pervasive and

unexpected• Yearning and longing for the person who died• Pleasurable reveries


Grief-focused Mental Health Services

• Fire Department of New York Counseling Service Unit’s “Stay Connected” Program1

– Use a combination of peer outreach and professional counseling to address mental health needs of retiring 9/11 firefighters

– Peer involvement and intensive community outreach (e.g., social events), wellness activities, and classes, were integral to the success of the intervention

• Traumatic Grief Counseling2,3

– Treatment protocol uses imaginal re-living of the death, in vivo exposure to avoided activities and situations, and interpersonal therapy

– Significant improvement in grief symptoms and associated anxiety and depression

– Response rate was greater for complicated grief treatment (51%) than for interpersonal psychotherapy (28%, p = .02) and time to response was faster for complicated grief treatment (p = .02). Number needed to treat was 4.3

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1. Alvarez J et al. Prehospital and Disaster Medicine, 2007; 22(1):49-542. Shear MK et al. American Journal of Psychiatry, 2001;158:1506-1508. . 3. Shear K et al. Journal American Medical Association, 2005; 293(21):2601-2608


• “the ability of adults in otherwise normal circumstances who are exposed to an isolated and potentially highly disruptive event such as a violent or life-threatening situation to maintain relatively stable, healthy levels of psychological and physical functioning” – Resilient individuals experienced generally healthy adjustments in the

months following 9/11

• Predictors of resilience

Psychological Resilience after Human-Made Disaster1

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1. Bonanno GA et al., Journal of Consulting and Clinical Psychology, 2007;75(5);671-682.

• Gender (Male) • Absence of depression and substance use

• Education level (Less education)

• Less income loss, social support and fewer chronic diseases

• Race-ethnicity (Asian) • Less direct impact of 9/11, fewer recent life stressors, and fewer past prior traumatic events

• Age (Older) • Not experienced an additional traumatic event since 9/11


Attitudes and Behaviors that Can Help Maintain Well-being during Stress1

• Positive outlook: Using cognitive-behavioral strategies to enhance optimism and decrease pessimism; embracing humor

• Active coping style: Problem-solving and managing emotions that accompany stress; learning to face fears

• Cognitive flexibility: Finding good in adverse situations; remaining flexible in one’s approach to solving problems

• Moral compass: Developing and living by meaningful principles; putting them into action through altruism

• Physical exercise: Engaging in physical activity to improve mood and health

• Social support: Developing and nurturing friendships; seeking resilient role models and learning from them

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1. Haglund MEM et al. Development and Psychopathology, 2007;19:889-920.


Basics of Psychological First Aid (PFA)

What• Establish safety and security, connect to restorative resources, reduce stress-related

reactions, and foster adaptive short- and long-term coping.

For• Individuals experiencing acute stress reactions or who appear to be at risk for significant

impairment in functioning.

By • Mental health professionals and others who provide crisis assistance after catastrophic

events

When• Immediate and early phase post-event, in as little as 30 minutes and extended as

needed

Where• In a broad range of emergency settings, in either single or multiple sessions, adapted fur

use in group settings.

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1. National Child Traumatic Stress Network & National Center for PTSD, Psychological First Aid: Field Operations Guide, 2nd Edition. July, 2006. Available on: www.nctsn.org


Coping More Effectively with Stress after a Mass Shooting1

1. Difficulty with sleep, irritability, and trouble concentration are normal responses following a mass shooting; talk with primary care provider if symptoms persist or cause problems with relationships or performance at home or work

2. Stay connected with other people

3. If going to public places or traveling causes distress, go with other people or in groups until distress reduces

4. Check in with other people that were affected

5. Avoid increasing alcohol and tobacco to cope with stress; use behavioral techniques to relax (such as breathing, imagery, and muscle relaxation)

6. Be cautious of news or other commentary that scapegoats large groups of people for the actions of a single individual

7. Limit exposure to graphic images and videos on the news and social media

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1. Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences. www.cstsonline.org/.


Pharmacotherapy for PTSD

• Medication treatments can be effective in treating PTSD, acting to reduce its core symptoms as well as associated depression and disability1

– SSRIs as first line agent for PTSD

• Despite numerous studies, the evidence fails to provide clear guidelines for the immediate post disaster population to prevent psychopathology2

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1. Stein DJ et al. Cochrane database of systematic reviews. 2006;1.2. Birur B et al. Psychopharmacology Bulletin. 2017;47(1):8-26.


What Helped after a Human-Made Disaster?: Survivors’ Perceptions1

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1. Hull AM et al. The British Journal of Psychiatry, 2002;181(5):433-438.

• Interviewed survivors (n = 33) of the Piper Alpha oil platform disaster, 10-years post-disaster

• Perceived helpfulness of the treatment and support systems used:

Treatment Support ServicesIndividual Psychotherapy – 44% Helpline – 93%Group Psychotherapy – 14% Support group – 83%Medication – 28% Reunion – 83%


Disaster Resources

• SAMHSA Disaster App– https://store.samhsa.gov/apps/disaster/

• SAMHSA Website– https://store.samhsa.gov/shin/content/SMA14-4873/SMA14-

4873.pdf– https://store.samhsa.gov/product/SAMHSA-s-Disaster-

Kit/SMA11-DISASTER

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Questions


Closing


Upcoming Virtual Fora*

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Psychiatric Illness Identification and Treatment for Mass Casualty Event Survivors

and First Responders

September 2018 MRC2.CORP.D.00377

psychiatric illness identification & treatment for mass ......and first responders . october...

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