1. The Role Consultation Liaison Services when Disaster Strikes A C McFarlane AO Professor of Psychiatry Centre for Traumatic Stress Studies The University of Adelaide

2. The Nature of Disasters Collective social suffering, reinforce sense of collective interest Collective social suffering, reinforce sense of collective interest Demonstrate the limits of technology to control Demonstrate the limits of technology to control Less stigmatisation of victims than singular events and confront vulnerability Less stigmatisation of victims than singular events and confront vulnerability Benchmarks in history of communities Benchmarks in history of communities

3. Tangshan Earthquake 28th July 1976 28th July 1976 242,000 dead and 164,000 badly injured 242,000 dead and 164,000 badly injured Gang of Four - media propaganda concern for victims Gang of Four - media propaganda concern for victims Earthquake phobia lead to major activism throughout the country Earthquake phobia lead to major activism throughout the country Slogans read: “Be alert to Deng Xiaoping’s criminal attempt to exploit earthquake phobia to suppress revolution!” “There were several hundred thousand deaths. So what? Denouncing Deng Xiaoping concerns eight hundred million” 6/10/1976 Mme Mao arrested 6/10/1976 Mme Mao arrested pg 65-66 Wild Swans, Jung Chang pg 65-66 Wild Swans, Jung Chang

4. 1983 Ash Wednesday Bushfires 808 Primary school children 808 Primary school children 2600 registered disaster victims 2600 registered disaster victims 459 CFS firefighters 459 CFS firefighters 320 patients 320 patients Interviewed the departmental relief co- coordinators Interviewed the departmental relief co- coordinators Surveyed disaster relief teams Surveyed disaster relief teams Post disaster litigation Post disaster litigation

5. Disaster Experience Melbourne/Voyager 82 men killed 1964 Melbourne/Voyager 82 men killed 1964 Ash Wednesday Bushfire Disaster Ash Wednesday Bushfire Disaster Yunnan Earthquake 800 deaths Yunnan Earthquake 800 deaths Iraqi invasion of Kuwait Iraqi invasion of Kuwait Kobe earthquake 3000 deaths Kobe earthquake 3000 deaths Bali Bombing 82 deaths and second bombing Bali Bombing 82 deaths and second bombing Port Arthur Massacre - single most killings by a single gunman Port Arthur Massacre - single most killings by a single gunman Australian Defence Force - soldiers in peace keeping in Rawanda and Timor and Middle East Area of Operations Australian Defence Force - soldiers in peace keeping in Rawanda and Timor and Middle East Area of Operations Boxing Day Tsunami 2005 Boxing Day Tsunami 2005 Eyre Peninsula and Black Saturday Bushfires 2009 Eyre Peninsula and Black Saturday Bushfires 2009 Mine accident, roof collapse in golf club, school bus accident,shooting of doctor, murder of director of mental health services, ship wrecks, show ride collapse, rail accidents. Mine accident, roof collapse in golf club, school bus accident,shooting of doctor, murder of director of mental health services, ship wrecks, show ride collapse, rail accidents.

6. Disasters: Lessons for Service Delivery Predictable morbidity in exposed population Predictable morbidity in exposed population –Vary for degree of exposure and losses Optimal public health intervention Optimal public health intervention –Population based –Primary and secondary prevention –Evidence based treatments

7. Time Windows of Service Planning Pre-traumatic Pre-traumatic Warning Warning Traumatic exposure Traumatic exposure Acute posttraumatic / Rescue Acute posttraumatic / Rescue Medium term period / Recovery Medium term period / Recovery Chronic phase of readjustment or re-establishment of life. Chronic phase of readjustment or re-establishment of life.

8. Post Disaster Service Delivery The consultant and relationship with postdisaster planner The consultant and relationship with postdisaster planner The role and skills of the service providers The role and skills of the service providers The expectations of the victims/patients The expectations of the victims/patients

9. Acute Post disaster Rescue Phase

10. Disasters in Context What are the mental health services in the affected areas? What are the mental health services in the affected areas? How adequately do they meet the existing need in those communities? How adequately do they meet the existing need in those communities? If a post disaster mental health program is put in place, will that add to or take away from existing services If a post disaster mental health program is put in place, will that add to or take away from existing services Ensure that any initiatives improve the existing delivery of services Ensure that any initiatives improve the existing delivery of services

11. Debriefing Not effective and should not be practiced Not effective and should not be practiced Encourages short-term focus of media and health services Encourages short-term focus of media and health services Screening is the central strategy Screening is the central strategy

12. Time Frames of Service Demand MedicalServicesRehabTreatmentPsychiatryServices ACUTE/RESCUE ++++ ++++ - + MEDIUM/RECOVERY + ++ ++ CHRONIC/ RESTORAT N - + +++ +++

13. Victims Reaction to Symptoms To be expected To be expected Time will improve Time will improve Demand for self hardiness Demand for self hardiness Stigma and shame Stigma and shame Avoidance Avoidance Confusion about the meaning of experience - onset of somatic symptoms Confusion about the meaning of experience - onset of somatic symptoms

14. Medium term recovery phase

15. Role of Primary Health Care Networks Victims prefer to use the existing health care providers Victims prefer to use the existing health care providers Good quality care for physical injuries and adequate pain management Good quality care for physical injuries and adequate pain management Do not compete with but integrate with their service delivery and locations, if possible Do not compete with but integrate with their service delivery and locations, if possible Support and educate Support and educate

16. Saw doctor about physical health complaint PTSD No PTSD (n = 77)(n = 70) Respiratory19% 4%6.69 * Musculoskeletal39%22%4.00 ** Cardiovascular14% 9%0.52 Gastrointestinal13% 6%1.06 Dermatological17% 9%1.46 Urological 1% 4%0.16 Headaches & funny turns17% 9%1.45 * P<0.05**P<0.01

17. Organizational Issues Managing the politics of the health care system and disaster relief Managing the politics of the health care system and disaster relief Leadership and expertise - new structures and response paradigms Leadership and expertise - new structures and response paradigms Effective interaction with disaster managers and emergency service leaders in future disaster planning Effective interaction with disaster managers and emergency service leaders in future disaster planning Managing positive outcomes in a compensation environment Managing positive outcomes in a compensation environment

18. Chronic posttraumatic re- establishment phase

19. Chronic posttraumatic/Re- establishment phase Withdrawal of public interest Withdrawal of public interest Maintenance of recognition of special needs of community Maintenance of recognition of special needs of community Reintegration into the mainstream structures Reintegration into the mainstream structures Sustaining expertise to be used with the victims of singular events Sustaining expertise to be used with the victims of singular events

20. Identification of Post Disaster Morbidity KNOWNDISORDER SUBCLINICAL UNKNOWNDISORDER TOTAL DISASTER POPULATION

21. Screening after London Bombings Problems of getting access to population Problems of getting access to population Defined high risk groups Defined high risk groups 71% screened positive 71% screened positive PTSD the predominant diagnosis PTSD the predominant diagnosis Treatment given to 82 with large effect size Treatment given to 82 with large effect size More referrals from screening than GPs who had been contacted More referrals from screening than GPs who had been contacted Brewin et al, 2008 Journal fo Traumatic Stress, 21 3-8 Brewin et al, 2008 Journal fo Traumatic Stress, 21 3-8

22. Public Health Perspective The possible interventions The possible interventions –Do not over-estimate value of prevention Planning and coordination Planning and coordination –Part of general health policy The identification of those at risk The identification of those at risk Need a mental health literacy program Need a mental health literacy program

23. The issue of the pattern of onset PTSD Severe acute distress is the exception and progressive increase of symptoms is very common

24. Percentage of psychiatric cases in children after a bushfire

25. Prevalence of PTSD after a mass traumatic event

26. Trajectory 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.

27. Course of PTSD symptoms after 9/11 (Norris et al, 2009) 1267 with all 4 data points up to 42 months 1267 with all 4 data points up to 42 months 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 most common pattern of response

28. Progression of cases at 24 months in accident and work injuries n=96 At 3 months 35.9% had full diagnosis At 3 months 35.9% had full diagnosis »44.1% reported minimal symptoms At 12 months 49% had full diagnosis At 12 months 49% had full diagnosis »26.7% reported minimal symptoms There is a progressive emergence of disorder at with time which means there is a need for repeated reassessment There is a progressive emergence of disorder at with time which means there is a need for repeated reassessment Coping in the immediate aftermath does not mean an individual will not develop PTSD or chronic pain later Coping in the immediate aftermath does not mean an individual will not develop PTSD or chronic pain later

29. 60 Month Follow Up Chronic 4.0% Delayed onset 9.6% Delayed onset (resolving) 8.1% No symptoms 72.5% Acute resolving 5.7%

30. The Conceptual Challenge Posed by Traumatic Stress Individuals who coped at the time of stress exposure became unwell many years later Individuals who coped at the time of stress exposure became unwell many years later What model of psychopathology could account for this lingering and delayed impact of extreme adversity? What model of psychopathology could account for this lingering and delayed impact of extreme adversity? The issue of delayed onset PTSD The issue of delayed onset PTSD

31. The issue of delayed onset PTSD Severe acute distress is the exception and progressive increase of symptoms is very common

32. Posttraumatic Sensitization Disorder The risk of PTSD following first exposures is less than later exposures

33. Do not forget the background psychiatric morbidity of the population

34. Post Disaster Morbidity PTSD Traumatic Event Other Psychiatric Disorder Total Population

35. 2007 ABS National Epidemiology Survey 8,841 people - 60% response rate 8,841 people - 60% response rate Over 16 years - life time and 12 month prevalence Over 16 years - life time and 12 month prevalence »45% had a life time disorder »20% 12 month prevalence 26% of young adults (16-24) 26% of young adults (16-24) 12 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 disorder Most common disorder - PTSD 6.4% Substance Use Disorder 5.1% Substance Use Disorder 5.1% »Alcohol harmful use 2.9% »Alcohol dependence 1.4%

36. GHQ cases 5 months after Yunnan Earthquake Control n=908 Disaster group n=1294

37. The Challenge to Maintain Postdisaster Skills Extend the treatment skills and health service delivery system developed after the disaster into other appropriate settings Extend the treatment skills and health service delivery system developed after the disaster into other appropriate settings »Individual trauma victims and chronically mentally ill To plan for the next disaster and to set training and health care plans To plan for the next disaster and to set training and health care plans To modify services and plans in light of emerging research To modify services and plans in light of emerging research

38. Disasters v’s Individual Trauma Disasters Individual Traumatic events Car Accidents Victims of Crime Military Rape victims Child abuse Torture Victims Mental Health Resources Specialized trauma Services Consultation and liaison services

39. The quality of research ?decreasing as the field matures Norris 2006 Journal of Traumatic Stress Norris 2006 Journal of Traumatic Stress 225 disaster studies 225 disaster studies Fewer using longitudinal studies and representative samples Fewer using longitudinal studies and representative samples Early assessments have been increasing Early assessments have been increasing Need to attend to the fundamentals of epidemiological research Need to attend to the fundamentals of epidemiological research

40. Design type by year: The proportion of longitudinal studies has been decreasing Norris 2006

41. Black Saturday 7 th February 2009

42. Impact of Change of Wind Direction

43. Similarity of Weather Systems Ash Wednesday Ash Wednesday Black Saturday Black Saturday

45. Black Saturday 48 hours before the Premier highlighted the extraordinary fire risk 48 hours before the Premier highlighted the extraordinary fire risk Headline on day of the disaster-before the fires- “Worst day in History” Headline on day of the disaster-before the fires- “Worst day in History” 173 People killed 173 People killed 2,600 buildings destroyed 2,600 buildings destroyed Area 1.1 million acres – Japan is 93 mil Area 1.1 million acres – Japan is 93 mil Injured 600 + Injured 600 +

46. Ash Wednesday Disaster 75 people killed 75 people killed 2676 injured 2676 injured Over 3700 buildings destroyed Over 3700 buildings destroyed 1,032,000 acres burnt 1,032,000 acres burnt

47. Lessons Learnt Academic Study of mental health outcomes does not record critical issues for survival behaviour Academic Study of mental health outcomes does not record critical issues for survival behaviour Warnings are not expressed in language or forms that change behaviour Warnings are not expressed in language or forms that change behaviour Journalists do not record or report critical facts Journalists do not record or report critical facts Failure to learn from past lessons Failure to learn from past lessons

48. The role of mental health professionals Collectors of isolated stories Collectors of isolated stories Need for case studies Need for case studies Advocacy role for communities and victims Advocacy role for communities and victims Issues of insurance and the rhetoric of commercial interests Issues of insurance and the rhetoric of commercial interests Self serving media management by government does not encourage facing the failures and learning Self serving media management by government does not encourage facing the failures and learning

49. Problems with the field The long term course is not adequately considered The long term course is not adequately considered What conveys the long term risk? What conveys the long term risk? The issue of trauma and other disorders- is the risk specific to PTSD? The issue of trauma and other disorders- is the risk specific to PTSD? Missing lessons of the past and reinventing what is know Missing lessons of the past and reinventing what is know

50. The Conceptual Challenge Posed by 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

51. Thank you

52. Prof AC McFarlane Centre of Military and Veterans Health The University of Adelaide 122 Frome Street Adelaide South Australia Australia 5000 Telephone 61 88303 5200 Fax 61 88303 5368 Email alexander.mcfarlane@adelaide.edu.au