Discussion - Mental Health Consequences of Natural & Human Made

Mental Health Consequences of Natural & Human Made Disasters Discussion

Read the article and answer the questions listed below:

• Describe the mental health consequences of natural and human-made disasters for public health and public safety workers.
• In regards to mental health consequences, what are the exposure differences between different types of first responders ( Eg: Police vs. Fire Department)?
• What is your impression of the public health intervention Models?

ANRV305-PU28-04 ARI 

First Responders: Mental Health Consequences of Natural and Human-Made Disasters for Public Health and Public Safety Workers∗ David M. Benedek, Carol Fullerton, and Robert J. Ursano Center for the Study of Traumatic Stress, Uniformed Services University School of Medicine, Bethesda, Maryland 20814-4799; email: dbenedek@usuhs.mil, cfullert@erols.com, rursano@usuhs.mil Annu. Rev. Public Health 2007. 28:55–68 Key Words The Annual Review of Public Health is online at http://publhealth.annualreviews.org public health workers, critical incident, disaster, traumatic stress response This article’s doi: 10.1146/annurev.publhealth.28.021406.144037 c 2007 by Annual Reviews. Copyright All rights reserved 0163-7525/07/0421-0055$20.00 ∗ The U.S. Government has the right to retain a nonexclusive, royalty-free license in and to any copyright covering this paper. Abstract First responders, including military health care workers, public health service workers, and state, local, and volunteer ?rst responders serve an important role in protecting our nation’s citizenry in the aftermath of disaster. Protecting our nation’s health is a vital part of preserving national security and the continuity of critical national functions. However, public health and public safety workers experience a broad range of health and mental health consequences as a result of work-related exposures to natural or man-made disasters. This chapter reviews recent epidemiologic studies that broaden our understanding of the range of health and mental health consequences for ?rst responders. Evidence-based psychopharmacologic and psychotherapeutic interventions for posttraumatic distress reactions and psychiatric disorders are outlined. Finally, the application of public health intervention models for the assessment and management of distress responses and mental disorders in ?rst-responder communities is discussed. 55INTRODUCTION ASD: acute stress disorder Annu. Rev. Public Health 2007.28:55-68. Downloaded from www.annualreviews.org Access provided by Tulane University on 11/06/18. For personal use only. PTSD: posttraumatic stress disorder 56 The terrorist attacks of September 11, 2001, focused the attention and energy of the United States on the “global war on terrorism” and the Nation’s security. This was further emphasized by the anthrax attacks of 2001, the response and recovery efforts of the 2004 Southeast Asia tsunami, the multiple hurricanes that struck Florida in 2004, and hurricanes Katrina and Rita in 2005. Natural and human-made tragedies (e.g., war) have demonstrated the extent to which our national infrastructure can be threatened, damaged, or destroyed by disasters. These events have emphasized the important role of our public health and public safety ?rst responders—including uniformed services, military and public health, and state, local, and volunteer ?rst responders—in protecting our nation’s citizenry in the aftermath of disaster. The de?nition of “public health workers” is somewhat arbitrary. Police, ?re?ghters, search and rescue personnel, and emergency and paramedical teams are included in most de?nitions and have been studied most extensively. However, nurses, physicians, laboratory personnel, and ancillary hospital staff have also played important roles in the responses to recent natural disasters in the United States and abroad, in rescue-andrecovery operations after terrorist attacks, and in the identi?cation, management, and treatment of infectious outbreaks such as SARS. These providers will no doubt play important roles in response to future natural and humanmade disasters, in particular an Asian in?uenza pandemic. Truck drivers, heavy equipment operators, laborers and carpenters have also worked (and continue to work) to restore basic needs such as shelter and workspace in the aftermath of natural disasters, limiting the spread of infection or disease related to environmental exposure or malnutrition. Others have assisted in the recovery of human remains, reducing infection and bringing a degree of closure to survivors of deceased vic- Benedek · Fullerton · Ursano tims. These efforts, which augment the roles of traditional ?rst responders, call for an expanded de?nition of “?rst responder” and may also suggest an expanded de?nition of “public health worker.” Regardless, protecting the health of care providers and other responders is an important aspect of disaster recovery and of preserving continuity of critical community functions. Within various responder groups, the potential negative emotional consequence of disaster work resulting from exposures to traumatic events, high levels of work demand, work with disrupted communities and evacuee populations, and separation from home and loved ones has been the subject of considerable investigation. Acute stress disorder (ASD) and acute and chronic posttraumatic stress disorder (PTSD) are the focus of considerable study (3). The broad range of posttraumatic reactions which can affect health, performance and morbidity include not only these disorders but also subclinical emotional symptoms (e.g. fear), altered health risk behaviors and other traditional disorders. Ultimately, healthy adjustment (resilience) should be expected in most, however, traumatic responses include: distress, worry, disturbed sleep or concentration, alterations in work function, dif?culties with interpersonal relationships, increase in substance use, somatization, and depression (8, 25). Response to loss of loved ones or significant others may include symptoms of traumatic grief (24) or complicated grief (39, 43). The intertwined nature of distress related behaviors, sign and symptoms of mental disorders, and distress responses not amounting to diagnosable mental disorders are depicted in Figure 1. In the following pages we review the spectrum of emotional and behavioral consequences of traumatic events as part of understanding the effects of disaster work on public health responders. We address recent advances in our understanding of the health, particularly mental health, consequences of disaster in public health workers and ANRV305-PU28-04 ARI   17:5 individual patient treatment, populationbased approaches, and public health intervention strategies for mental health consequences in disaster-affected communities. Public health planning and response must address these needs of public health ?rst responders. Annu. Rev. Public Health 2007.28:55-68. Downloaded from www.annualreviews.org Access provided by Tulane University on 11/06/18. For personal use only. CONSEQUENCES OF TRAUMATIC EVENTS Psychological and physical responses to traumatic events (e.g., actual or threatened death or serious injury) vary with the social context of the event, biological and genetic makeup, and past experiences and expectations. These factors interact with the characteristics of the traumatic event (e.g., cause, intensity, duration of exposure, availability of medical and psychosocial support) to produce psychological and behavioral responses that range from resilience to disability. Three categories of response and their needed interventions have been described (25): Most people may experience mild, transient distress such as sleep disturbance, fear, worry, anger, or sadness or increased use of tobacco or alcohol. Persons experiencing such responses may return to normal function without treatment but might bene?t from community-wide support and educational interventions. A smaller group may experience moderate symptoms such as persistent insomnia or anxiety or changes in travel patterns or workplace behavior. Although these changes would not necessarily meet threshold criteria for disease or disorder, such symptoms may affect work or home functionality. These symptoms will likely bene?t from psychological and medical intervention. A smaller subgroup may develop psychiatric illness such as PTSD or major depression and will require specialized treatment. Epidemiologic studies in the aftermath of natural disaster and terrorism have identi?ed subpopulations at particular risk for severe outcomes. These include children, the elderly, those with chronic mental and physical illness, and those with limited social support (19). The number of people experiencing symptoms from each of the three severity categories varies with the nature of the event (e.g., man-made deliberate attacks have generally been associated with greater pathology than natural disasters have). Proximity, duration, and intensity of exposure are the most signi?cant predictors of outcome severity.

POSTTRAUMATIC CONSEQUENCES AND PUBLIC HEALTH WORKERS

Health Care Providers in High-Stress Environments: Life Threat, Trauma, and Terrorism Exposures Our understanding of the effects of highstress environments on health care providers has progressed considerably through the study of health care delivery in military con?ict and peacekeeping missions. In the health care populations where combat or threat of personal injury is minimal (44), symptoms of depression and anxiety were noted. However, investigators have observed long-term disability in health care workers working in lifethreatening military environments. Carson et al. (12) studied Vietnam nurses with PTSD from their wartime experiences, decades after their return from war. Even at this late time, this group experienced signi?cant physiologic response to scripts describing their work with injured soldiers. Many of these nurses had been exposed to life-threatening events during their wartime experiences, but the extent to which PTSD resulted from observation of the injuries of others, personal threat or injury, or an interaction of these factors was not clari?ed. Grieger et al. (21) studied tertiary care hospital workers (physicians, nurses, and www.annualreviews.org • First Responder Health and Mental Health 57 ARI   17:5 support personnel) who deployed on a hospital ship during Operation Iraqi Freedom and compared responses to nondeployed workers from the same hospital. In this relatively small sample, degree of exposure to the dead or injured others was not a signi?cant risk factor for PTSD or depression. However, perceived threat of harm to self predicted the subsequent development of PTSD. Rates of depression, PTSD, and health care and mental health care utilization in the deployed group were significantly higher than in nondeployed controls. This study suggested that in a group of experienced military health care workers, threat of personal harm in the high-stress environment of the combat theater setting was important in predicting illness and health care utilization for care providers returning from a military combat–related deployment. Nurses practicing in hospital settings requiring routine and repeated exposure to seriously injured trauma victims show higher levels of general anxiety than do their lessexposed counterparts (27). A recent study of Turkish health care workers (1) found that those reporting traumatic exposure—from either natural disaster or terrorist event— acknowledged PTSD symptoms at twice the rate of those without traumatic exposure. However, this study did not differentiate between exposure to disaster or exposure to terrorism, nor did it distinguish the nature of the traumatic exposures (observed injury to others versus perceived threat of injury to self). Moreover, Akbayrak et al. (1) did not use established criteria for the diagnosis of PTSD or other speci?c psychiatric disorder and demonstrated only the presence or absence of emotional, physical, or cognitive symptoms related to de?ned illnesses. In a study of health care workers following the Washington, D.C., sniper attack, Grieger et al. (21) found increased alcohol use, depressive symptoms, and PTSD symptoms as well as altered safety behaviors (e.g., driving habits, participation in public events). As with other surveys of health care workers, this study was limited by the small sample size and retro- Annu. Rev. Public Health 2007.28:55-68. Downloaded from www.annualreviews.org Access provided by Tulane University on 11/06/18. For personal use only. ANRV305-PU28-04 58 Benedek · Fullerton · Ursano spective, self-reported symptom quanti?cation. However, the study suggested, again, that health care workers are not immune to the psychological consequences of terrorism. In sum, these studies of health care providers working in nontraditional high-stress environments suggest the need for greater study of the degree to which personal risk, exposure to the injury of others, and the requirement to deliver care away from one’s usual workplace may interact to produce behavioral changes, distress, or disorder in health care workers. Health Care Workers and Epidemics Studies of the psychological effects of epidemics on health care workers are limited. Bai et al. (5) examined health care workers (N = 402 care providers, and N = 155 administrators) at a veteran’s hospital in Taiwan shortly after 57 hospital workers had been quarantined as a result of the SARS epidemic. Five percent met American Psychiatric Association Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) criteria for ASD, and quarantine itself was the strongest predictor of this diagnosis. Twenty percent reported experiencing feelings of stigmatization and rejection in their home neighborhoods. Nine percent of the health care workers reported either a reluctance to work and/or considered resigning in the period surrounding the quarantine. Results indicated that psychological disorder and distress, as well as the potential for health care worker absenteeism, were important in planning for future epidemics. The hospital surveyed was not a SARS treatment facility so the extent to which rates of distress and absenteeism might be more (or less) of a factor in a facility dedicated to epidemic treatment remained subject to speculation. Maunder et al. (29) examined patients and treatment personnel in a SARS treatment facility during an outbreak. They found incidents of professional isolation (as a result of mask use and recommendations to avoid unnecessary contact with fellow workers), ANRV305-PU28-04 ARI   17:5 diminished morale in some care providers, and professional and administrative workrefusal during the height of the outbreak. Public health planning for work absence and workforce morale are indicated. Annu. Rev. Public Health 2007.28:55-68. Downloaded from www.annualreviews.org Access provided by Tulane University on 11/06/18. For personal use only. Firefighters Some ?rst responders must confront the injuries and death associated with natural disaster, at times under the threat of personal injury. Bryant’s early studies of volunteer ?re?ghters in Australia (9, 10) noted that proximity to death, severity of trauma, and perceived threat were all associated with the development of posttraumatic symptoms and PTSD. Subsequent study (6) con?rmed perception of threat to self as highly stressful to ?re?ghters, but it suggested that “routine” aspects of duty such as performing CPR may be stressful to ?re?ghters. Also contributing to symptom development were disaster-related postdisaster personal events such as loss of a loved one, unemployment, and involvement in subsequent critical incidents. In a longitudinal study of Australian ?re?ghters, 77% of the subjects who had developed PTSD had a comorbid psychiatric diagnosis such as depression, panic disorder, or phobic disorders (31). These studies highlight that for ?rst responders, just as in the disaster-affected community, disasters do not occur in a vacuum. Their signi?cance must be interpreted in light of other social and interpersonal events that may occur as a result of the disaster itself or may be unrelated. Studies of ?re?ghters have generally found rates of PTSD ranging from 13% to 18% 1– 4 years following large-scale response events (20, 31, 35). Heinrichs et al. (23) reported a 2-year prospective follow-up of 43 ?re?ghters assessed initially at completion of basic training and then at 6, 9, 12, and 24 months for symptoms of depression, PTSD and anxiety, biological makers of stress (salivary cortisol and 24-hour urine catecholamine excretion), and a variety of personality traits. Investigators did not measure symptoms related to a speci?c traumatic event. Although biological markers did not predict symptoms, the investigators found that a high level of hostility and a low level of self-ef?cacy accounted for 42% of the variance in posttraumatic stress symptoms after 2 years. Moreover, subjects who had both risk factors at baseline had signi?cant increases in measures of PTSD symptoms, depression, anxiety, general psychological morbidity, and global symptom severity during the two-year period. These results suggested that speci?c personality traits may constitute markers in one’s vulnerability to psychopathological symptoms after trauma exposure in populations of public health ?rst responders. In a longer-term study Morren et al. (32) compared 246 volunteer ?re?ghters, who deployed in response to a technological disaster, with 71 nondeployed controls in a questionnaire assessing perceived health and health change, mental health problems, and health care utilization. Three years after the disaster no health differences emerged between deployed and nondeployed ?re?ghters, although disaster-related experiences (e.g., rescuing victims, ?re extinguishing, and body recovery) predicted posttraumatic stress symptoms, health care utilization, and mental health care utilization. As earlier studies of ?re?ghters (9, 10) have shown, distressing experiences unrelated to the disaster were predictors of health problems and health care utilization. Police Officers In a study comparing 709 police of?cers with 317 civilians exposed to a variety of critical incidents, Fikretoglu et al. (18)