Psychological Problems Expected After Japanese Disaster

Psychological problems are expected after the recent earthquake and tsunami in Japan. In the past American psychiatrists with experience in disaster psychiatry have offered assistance to colleagues in other countries who are dealing with a catastrophic event and it is expected that this will occur with the current incident. In the initial phase psychological first aid will be given to the survivors and then symptoms of acute stress will be addressed. Between 10-50% of those impacted can be expected to develop symptoms of post traumatic stress disorder. Expertise in risk communication will also be helpful in dealing with the task of informing the public. This becomes especially relevant with the threat of radiation contamination from damaged nuclear reactors.

As the earthquake and tsunami disaster in Japan unfolds, we cannot help but feeling helpless and overwhelmed as we learn of the increasing death and injury toll and see the tremendous destruction. Even though some of us as psychiatrists and other mental health professionals have worked in disaster situations, very few of us have witnessed the magnitude of the events taking place in Japan.

Mental Health Experts will Offer Help

Edited by M. Blumenfield & R. Ursano

I am sure that there will be mental health specialists from the United States and elsewhere offering their assistance to our colleagues in Japan as has been the case with other major catastrophes. During the Kobe earthquake in Japan in 1995, I was a member of the Committee on Disasters of the American Psychiatric Association and we arranged to translate a good part of our mental health written materials for disaster into Japanese so I am sure they will be made available again  at this time. In that event and during subsequent events, American psychiatrists held conference calls with mental health professionals in impacted areas to offer the benefit of experience which we had from working in various events including plane crashes, The World Trade Center bombing, Oklahoma City, Katrina, 9/11 and other events. An organization called Disaster Psychiatry Outreach was formed by a group of young psychiatrists from New York who trained many psychiatrists who then participated in the mental health efforts in various locations throughout the world. For several years I participated with my colleagues in  teaching courses at the annual meeting of the American Psychiatric Association about disaster psychiatry. I am sure there will be many mental health professionals joining other volunteers  to assist the Japanese in dealing with this traumatic event.

I would like to briefly review some of the anticipated mental health issues in a disaster such as this one.

Psychological First Aid

Needless to say – the first effort is always rescue and attempt to save as many as lives as possible. All resources will be directed  towards  searching and finding the victims of this tragedy. First Aid to the victims should always have priority over mental health support but it should be given with Psychological First Aid.   this means that  food, water and shelter should be provided in a compassionate manner. An essential part of this effort is to communicate in efficiently and humanely  with families and loved ones who have survived.   Another part of this psychological first aid is going to be some kind of continued support to those who have suffered so many losses personal and material loses. The role of insurance, government support and foreign aid along with that of friends and family will be very meaningful and psychologically supportive.

Actual treatment might be better than a support group for some patients who have undergone severe trauma.

Not Just Grieving But Complicated Grieving

Edited by Fred Stoddard, Jr., Craig Katz, and Joseph Merlino

Whenever there is loss of life there is grieving by family, friends and I am sure by the entire country. Grieving is a universal process and while it is influenced by culture and religion, there are certain physical and emotional components of it that are well know by physicians, ministers, mental health professionals and anyone who has been around long enough to see such responses in themselves and others. There will be waves of emotions whenever anything reminds them of the loss, tears and depressive symptoms. While the lost person may never be forgotten, the severity of the symptoms and inability to function as before will usually improve over time with normal grieving. However a situation like this is one which falls into a different category usually named complicated grieving. Such a designation  is made when there is the death of large numbers of people especially when children are killed or large numbers of children are grieving, unexpected death often of horrible and bizarre circumstances. ( This designation also applies when there is murder or suicide which doesn’t apply here ).It is more likely to occur when the body has not been located and given a ceremonial funeral.  Complicated grieving usually is prolonged for at least a few years, sometimes longer. It is complicated by symptoms of severe depression and may lead to substance abuse and suicidal behavior. There is often a need of the  bereaved to to find an explanation for the event or seek some type of restitution. This may lead to tremendous anger directed towards the government and public officials even in a situation where there was a natural disaster. These feelings can  also get directed towards God and towards one’s religion. It becomes very meaningful for the government, and society to recognize the loss of lives. Memorial and commemorative services at anniversaries of the event as well as monuments and dedicated rebuilding becomes part of the healing process.

Acute Psychological Stress

By Robert Ursano, Carol S. Fullerton, Lars Weisaeth and Beverly Raphael

There are acute psychological stress symptoms which will occur in huge numbers of people in the days and weeks after the event.These will consist of extreme anxiety, depression, insomnia, bad dreams, flashbacks of the horrible events which they experienced, helplessness, numbing, detachment, feelings of unreality, depersonalization dissociative amnesia where a person can’t recall important aspects of the trauma, tendency to avoid anything or any thoughts to do with the trauma and a tendency to have an increased startle reaction or tendency to jump very easily. At this stage people are susceptible to abusing alcohol and drugs. It had been very common for peer groups and mental health professionals to organize debriefing group meetings where people who recently had been through a trauma would be encouraged to review  their experiences as well as their emotional responses including the personal meaning to them. It was thought that this approach could diminish the possibility of long term psychological symptoms. Subsequent research did not establish this as a valid approach and raised questions whether at times the group discussions created more anxiety in some individuals. While each situation is different and there are often limited psychological resources, the best psychological approach appears to be psychological first aid with warm supportive environment where the victims basic needs are met, valid information is supplied by caring people, efforts are made to connect with families, intermediate and long term planning is established and the victims are counseled about what type of psychological feelings they might be expected to have . People should be cautioned about tendency to abuse alcohol and drugs. During group meeting where information and other necessities are being provided, there should be screening for individuals who may need individual counseling, therapy with or without psychiatric medication.  People with pre-existing mental disorders may have an exacerbation of their condition although in some cases such people faced with an external catastrophic event may actually fare fairly well as they put aside their “personal demons” and actually cope better than usual. People with underlying mental conditions may need adjustment of their medication. In addition there can be an important role for the use of administering sleep medication , anti- anxiety medication of other psychotropic medication to some people during the acute phase of a trauma.

Post Traumatic Stress

By V. Alex Kehayan & Joseph C. Napoli

It is invariably that a certain number of people will go on to develop a post traumatic stress disorder where they can have persistent symptoms as described above. This can be quite distressing and incapacitating  for some people . There are several  psychological treatment techniques which may or may not include medication While the percentage is variable perhaps between 10-50% can have significant symptoms in months and years to come. We have learned that the majority of people in such situations have shown great resiliency and have a good psychological recovery over time . People closest to the areas of destruction are more likely to suffer although this is not invariably the case. Children are particularly vulnerable and should not be neglected in screening for emotional problems. Today with mass media, people watching the events can identify with their fellow countrymen and women and suffer symptoms. We now also know that there are psychological causalities among the police, fire, emergency personnel, hospital workers, morgue workers government officials and especially members of the working press who go out of their way to witness a great deal of the death and destruction.

Risk Communication

Mental health professionals can provide assistance and consultation in all phases of a disaster. There are also mental health experts who have studied the field of risk communication which is how public officials and the media provide information about potential danger. It has been shown that it is both essential for there to be a spokesperson who is trusted to deliver honest information to the public at the same time to do it in a manner to minimize fear and panic. This has been studied and there are techniques which this can be done in the most effective manner.

Psychologcial Impact of Radiation Threat

One additional thought related to the above issue of risk communication is the situation where there is the potential of radiation fallout to the communities surrounding nuclear plants which is the situation occurring as I am writing this. There was a similar situation in the United States with the Three Mile Island incident where there was a question of the accidental release of radioactive vapor into the air. Subsequent studies have shown that while there actually was no  physical danger many people suffered psychological symptoms especially women of child bearing age  and mother of small children who were highly anxious about the potential danger of radiation.

There are some excellent books on psychological issues in disasters which can be easily accessed. I have pictured  some of them in this blog. I welcome your thoughts on this very important current issue.

Haiti Earthquake-Psychological Care Needed

More than 150,000 people have died in the recent devastating earthquake in Haiti. There is fear, anxiety, depression and tremendous psychological pain. The uncertainty about the future will intensify these emotional reactions. Most likely the initial help by mental health professionals will be to assist the stunned people in getting food, shelter and information about the whereabouts of their loved ones. Psychiatrists may write prescriptions for general medical conditions or even assist in emergency surgery. There also is a need for the authorities to provide “risk communication” of truthful information. Death notifications need to be done skillfully. Mental health professionals can be helpful in training for these tasks. In the immediate aftermath of a disaster, people may deny the reality of what has happened. There will be grieving by survivors for the many people who perished. Grief after unexpected violent death especially when it includes children can be prolonged and complicated with additional emotional problems including alcohol and drug problems. At least half of the survivors will have some symptoms of PTSD. There are various forms of mental health interventions which may be helpful. The psychological effect of such a disaster can also impact on the secondary victims which include all rescue and medical personnel as well as members of the media. Psychiatrists and other mental health professionals will play an important role in helping the people of Haiti to recover from this ordeal.

I am writing this blog 12 days after the devastating earthquake in Haiti. We are seeing and hearing about the tremendous need for food, water, medical personnel and supplies. HAITIThere are head injuries, broken bones with people  dying of infections and other complications of their injuries as well as facing the prospect of starvation. We know from experiences in other disasters that there has to be fear, anxiety, depression and tremendous psychological pain among the people of Haiti. Thousands of people have been killed with unimaginable numbers of people injured, displaced from homes, separated from families, without food, water or  shelter. There is great uncertainty about the future for these people and this alone will intensify their emotional reactions.

Is There A Role For Mental Health Professionals ?

Of course, at this time  there is a need for psychiatrists and other mental health professional in Haiti. However, everything is relative. After the terrorist attack in New York on 9/11 there was an abundance of mental health experts immediately available. They were put to work on the Pier 92, which was where the services for the victims were being organized. They were not assigned to do psychological therapy but rather assisted in helping the stunned people to get food, shelter and assist them in finding what happened to  their loved ones. Their psychological and interpersonal skills were no doubt helpful in carrying out these tasks even though most were not initially doing formal therapy.

Psychiatrists who have become involved in previous disasters often will write prescriptions for heart, thyroid, diabetic and mostly other non- psychiatric medications which people need and did not have .  (See my previous blog on this subject) Psychiatrists may also participate in the delivery of general medical care or even assist in surgery during the early stages of a disaster response.

We would hope that the people organizing and delivering the immediate care to the victims in Haiti are sensitive to the psychological vulnerabilities of the victims, especially the children involved. The leaders of emergency services also need to understand how important it is to provide truthful information to the people involved without inducing additional fears and anxiety. There are  special techniques to do these “risk communications

In addition, the people doing death notifications to family and friends of those who died need to be knowledgeable and skilled in this difficult task.  Psychiatrists and other mental health professionals can be very helpful in training emergency workers for these tasks but the best time to do it is during emergency planning and  disaster preparedness.

Emotional Reactions in the Aftermath of Disaster

We all can imagine the fear and anxiety that people will initially feel when an earthquake occurs with immediate devastation. We can see the stunned look on the faces of the people in images from Haiti . It may take a while for the emotions to catch up with reality. In such a situation the people may become disconnected from their feelings (called dissociation).

Denial

Sometimes the people involved are actually denying the reality that has clearly occurred. DenialIn New York City immediately after the destruction of the World Trade Center thousands of people “disappeared”.  So many people did not come home that night and were buried in the rubble. Once it was established missing people were not registered at local hospitals, it should have been obvious that these people had perished. However families began posting “missing persons posters” all around Manhattan with a picture and a  description of the lost person with a phone number to call if the person were found. It took a week or two before the originators of most of these posters came back and changed the posters to memorials with people often putting flowers next to them. While this specific phenomena may not be occurring in Haiti, we can only imagine the difficulty that people are having adjusting to the sudden disappearance of important people in their lives. This is made even more difficult since, for most a funeral was not possible and for many the bodies will never be found.

Grieving

It was estimated that 10,000 children were grieving after the loss of a parent or a close relative following the 3000 deaths in the New York tragedy in 9/11. In Haiti more than 150,000 people are estimated to have died in this disaster so you can do the math as to acute grief among adults and children.  When people die violently, unexpected or when children are killed, the grieving that follows by their loved ones takes on special characteristics. It tends to be complicated by other psychiatric conditions such as post traumatic stress, major depression or even suicidal thoughts. Grieving in such situations tends to bring on alcohol and drug use in some people. It is more difficult to resolve all the powerful emotions especially the anger and the grief which can linger on for many years.

It is probably fair to say that the entire country of Haiti will be going through a prolonged grieving period but most people will not require psychological counseling even if it were available. The social networks including the church will provide most of the support. In fact, it has been shown that  following most disasters the majority of people will have great resiliency and will bravely deal with the tragedy albeit with a heavy heart. Their lives will be changed forever and they will never forget what happened. There will be memorials and anniversary events, which will be helpful to the grieving process.

Post Traumatic Stress

Having acknowledged the resiliency that most people will show after such mass trauma, many people will have at least some symptoms of post traumatic stress disorder ( PTSD). They will have recurrent and intrusive distressing recollections of the events that they have seen and been through. This can include nightmares and daytime flashbacks. At times people will act or feel as if the traumatic event were recurring. There may even be hallucinations or misperceptions where real things are misperceived as something related to the recent traumatic events. For example, the noise or vibrations of a passing plane or truck might immediately bring back a flood of the feelings that occurred during the earthquake. This can include rapid heart beat, fast breathing and other physical symptoms. When there are even mild after-shocks following a major earthquake some people are overwhelmed with emotion.

In the aftermath of such an event,  people suffering post traumatic stress symptoms can make efforts to avoid conversations or thoughts associated with the trauma. They may avoid certain locations or even people who will remind them of the recent trauma. Some will feel detached and estranged from other people and may not be able to have any loving feelings for a long time. There can be difficulty in falling or staying asleep, increased outbursts of anger, difficulty concentrating and hypervigilence. Quite characteristically people who are having symptoms of post traumatic stress will have an exaggerated startle response in which they can typically  appear to “jump out of their skin” after a loud or unexpected noise.

While at least 50 % of people exposed to the horrendous experience of a major earthquake can have one or more of these symptoms, perhaps only 10-15% will have significant symptoms lasting for more than one month in a pattern, which mental health professionals will diagnose as PTSD. Depending on the criteria used, some research has suggested higher numbers than I have stated above..

Treatment For Psychological Problems after a Traumatic Event

We have learned a great deal from past experiences, how to offer psychological help in the aftermath of a disaster. As previously mentioned, it is most important to assist with food shelter and help people find out about what happened to loved ones. In the past survivors were commonly offered a group technique called “critical incident stress debriefing (CISD)” where people were encouraged to relive their emotional experience in a supportive group environment. This technique has come under scrutiny as to whether it is the best technique or not and when and if  it should be used. Experience has taught disaster experts that while some group meetings maybe helpful, it is usually best to use them to provide survivors with needed information about coping with real issues as well some general information about the emotional reactions which they may be having, perhaps cautioning about the tendency in such a situation for some people to turn to alcohol and drugs. At the same time such meetings will allow mental health professionals to observe and identify the participants who may be doing poorly and require more specific individual or group therap. This treatment may be a specialized cognitive behavior type of treatment or more traditional psychotherapy

There has been some interesting research, which suggests that certain medications given during the early stage of disaster may prevent or minimize the development of posttraumatic stress symptoms. However at the present time medications of choice that are given are usually mild tranquilizers or sleep medication. Obviously people with severe symptoms or preexisting major mental disorders may require specific medications.

The Secondary Victims of Disaster

The psychological effects of a disaster not only potentially impact the people who live in Haiti or were there when the earthquake struck, but can also effect the emergency personnel who flowed into Haiti to provide services and who can  become secondary victims. This includes all the fire, police, rescue teams and military personnel as well as the many doctors, nurses, including mental health professionals. Even though many of these workers are used to seeing people who are traumatized, injured and dying or dead, the magnitude of this tragedy may be beyond anything that they have seen or experienced.

ANDERSON COOPERThe Media Are Often Neglected as Potential Victims of PTSD

The other night I saw Anderson Cooper, CNN anchor, reporting from Haiti. He was telling about the dead bodies of children being pulled out of the rubble and other very difficult scenes. He was clearly emotionally affected. It is the job of the working press to view the worst of all the destruction, talk to victims, as well as the families of those who have perished. They often work around the clock without much rest. I have had experience working with media people who have been through disasters and I have seen the emotional toll that can be taken on them. (See Page 42-43 of this reference)

Conclusion

It will not be easy for the Haitian people to get through this tragedy without emotional scarring. I know that among the many volunteers assisting them and their helpers will be psychiatrists and other mental health professionals who will play an important role in the recovery from this ordeal.

Your Comments are Welcome

Extra Rx Meds for Disaster Preparedness

After recently moving to California and experiencing a mild earthquake I decided to obtain an extra month supply of prescription medication for my family and myself as this is recommended for disaster preparedness. I found out that this is a very difficult thing to do and furthermore most insurance companies won’t pay for it. Experts working in disasters know that people frequently don’t have access to their everyday medications. While there may be some exceptions such as concern about addiction or suicidal tendencies, most people should have the ability to obtain an extra month supply of their medication above that which is usually prescribed for them. The author co-authored a resolution at the Assembly of the American Psychiatric Association that would have this organization work with other medical groups and interested parties to advocate that laws and regulations be changed to allow individuals to have extra medication on hand for emergencies and disasters. The readers of this blog were asked to check the situation where they live in the U.S. or internationally in regard to this problem and to report in the comment section of this blog.

Rock and Roll with A California Earthquakeseismogram

About a year ago my wife and I relocated from New York to Southern California. After many months of remodeling our new home , building a home office and setting up my practice I thought we were  settled and I  was now a Californian. Then I experienced my first earthquake. It was a relatively mild one I am told. But for 15-20 seconds it was a little rock and roll in our new house. We had lived in San Francisco many years ago during my internship but I had forgotten what these shakes feel like and how helpless you actually are during these occasions.

Sorry Your Insurance Won’t Pay For Extra Medication

BAG-SUPPLIES-EARTHQUAKE-W12So not surprisingly, I was mobilized to action as people often are when they experience an episode of helplessness. I ran out and  bought flashlights , a crankable radio, picked up a months supply of water and a first aid kit. I even bought “museum putty”  a product I never heard of before which fastens objects on bookcases and shelves to prevent damage during a shake.  Then I went to my local pharmacy to be sure we had at least an extra  month supply of our prescription medications for our emergency kit.  By this I mean an extra month that would be in place even if the usual month supply or 90 day supply was running down. My pharmacist says sorry you are not authorized for such . Well of course I could get my physician to write it for me or being a licensed physician I could write the prescription myself. However the pharmacist informed me, of what I should have realized, that even if I had a prescription for an emergency supply of medication, my insurance prescription coverage wouldn’t pay for it. The same rules apply to online purchases.

People Can Run Out of Medication  During A Disaster

I am not a newcomer to the study  of disasters. I  had served on the Dimensions of Disasters Committee of the American Psychiatric Association.  For the past several years I have taught a course for psychiatrists at the annual meeting of the American Psychiatric Association  with a New Jersey psychiatrist Dr. Joe Napoli . I also edited a book in this area with Dr. Bob Ursano Chair of the Department of Psychiatry of the Uniformed Services School of Medicine . We taught the participants of our course about the common knowledge among disaster experts that the most frequently dispensed medication to people in the aftermath of a disaster is not a tranquilizer or a sleep medication but rather prescriptions for the everyday medications, which they take and now no longer have access to or have run out of them.

Just recently I read the position statement of the American Association for Geriatric Psychiatry about Disaster Preparedness  sent to me by Dr. Morty Potash, a psychiatrist from New Orleans . In it was mentioned the fact that during Hurricane  Katrina  more than 56% of the persons who went to the Astrodome for shelter, 5,846 persons, were older than  65 year of age. Similarly, access to needed prescription medications represented a significant problem. Obviously, it can also be a problem for people of every age. Furthermore, the most common visits to Houston  Texas Emergency Rooms by people displaced by Katrina were for refills of existing medications suggesting that the usual resources for refills were absent. It stands to reason that there is a possibility of medical offices  being made unavailable by the disaster, physician and staff being injured or predisposed caring for other victims.

A Reserve Supply of Medication is Needed

Patients will need to have at least a month supply of their medications. We are talking about  the common heart medications, blood pressure medications, thyroid , insulin and other hormonal treatment , pill_bottlesantibiotics, medication for prostate and urinary  problems as well as cancer therapies and many less common types of treatment

Psychiatric patients will need access to their medications of course. Patients taking medication for panic disorder would be likely to have an exacerbation of attacks should they run out of medication and certainly the stress of an emergency situation would make this even more likely. Patients taking medication to stabilize a mood condition such as one of the bipolar mood disorders could decompensate as could a person with schizophrenia who no longer has access to antipsychotic medication . While it can take a few weeks, depression can reoccur after cessation of antidepressants.  The result of the return of serious depressive symptoms can be suicidal behavior . Research demonstrated that psychiatric medication among Manhattan residents following the World Trade Center Disaster increased.

As I mentioned, many people do get a 90 day supply of medication and may even have a prescription for three renewals .The ability of physicians to write prescriptions is regulated by the states with federal laws governing certain type of controlled medications. There may be some variations in different parts of the country . It appears to me that most states will not allow a full month supply of medication to be held on a continued basis ( with rotation if meds become outdated.) Also most if not all  insurance  plans do not allow or will not pay for  a renewal until a short time before the drugs run out which means that you can’t guarantee that you can put away a supply of medications for emergency planning.

It would seem logical that a physician should have the ability to write a prescription for an extra month supply of medication and provide instructions for rotations of the drug if there is concern about it being outdated. It also seems appropriate that insurance companies should pay for this extra supply of medication even though in most cases it won’t be used and will just be out there being rotated. ( I am sure the pharmaceutical companies won’t mind this situation.)

There Can Be Exceptions

It also is true that under some circumstances a physician may not want the patient to have more than a limited supply of a particular drug. This could be because the effects need to be evaluated before more meds are prescribed or perhaps because the physician may be concerned about potential addiction problems or even suicidal tendencies. In such situations the physician  properly might not write a prescription for extra medication  even if he or she were authorized to do so.

Can We Change the Regulations and Laws?

As a recent Past Speaker and therefore a member of the Assembly of the American Psychiatric Association I co-authored with several other psychiatrist including Dr. Napoli, mentioned above and Dr. Arshad Hussain from  Missouri who is  past Chair of the APA Committee on Dimensions of Disaster, a resolution to have the American Psychiatric Association to investigate this situation and advocate with other groups such the American Medical Association on the national level and State Medical Associations on the local level  so legislative regulations are altered to facilitate this aspect of disaster planning. This was approved by the Assembly in November in Washington D.C and I am hopeful that this organization will take up the advocacy with other interested parties mentioned above as well as with government agencies and.  insurance companies. I also spoke with my California State Assemblyman ( who happens to be my son ) who will look into this issue further in my state. These types of changes don’t occur quickly or easily.

Can You Survey Your Local Situation  ?

Although this weekly blog has only been up for a little more than two months we know that we are read in many states throughout the US as well as many countries. Can those of you who are iFinger pointinginterested in this issue check it out and determine if the average person can get an extra supply of medication for emergency preparedness where you live and would most insurance companies pay for it? Please send a comment on your findings to this blog ( below ). We will put it on within 12-24 hours. Perhaps we can get the data that will motivate those who make the laws and regulations. The power of the Internet can also help us get such information to the people who can make differences on  this issue both in the US and elsewhere. Lives could even be saved in the next disaster event.

Your Comments and Data on this Topic is Welcome