1. Central Asia Regional Health Security Workshop George C. Marshall European Center for Security Studies 17-19 April 2012, Garmisch-Partenkirchen, Germany Geoffrey J. Oravec, MD, MPH, MALD Capt, USAF, MC Center for Disaster and Humanitarian Assistance Medicine 19 April 2012 Mental Health in Disasters

2. Introduction What is a disaster? Why is mental health important? Affected populations Interventions

3. A serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses which exceed the ability of the affected community or society to cope using its own resources. - UN 1992 A situation or event which overwhelms capacity, necessitating a request to a national or international level for external assistance. Meets at least one of the following criteria: –10 or more people killed –100 or more people affected –Declaration of state of emergency –Call for international aid –Center for Research on the Epidemiology of Disasters What is a Disaster?

4. Disaster Risk Vulnerable Population Preparedness x = Hazard

5. Disaster Trends Affected Disasters Killed

6. Types of Disasters Individual Exposed = Trauma UnintentionalIntentional Community Exposed = Disaster Unintentional Natural Disasters Technological Intentional War and Terrorist Attacks Psychological Problems: greater number longer duration more complex

7. Why Mental Health is Important Mental health is the leading cause of disability in the world Major economic and social costs Increasing demands on the health system following disaster Decreased resources following disaster Decreased ability to respond, recover and rebuild

8. Causes of Stress Reactions Violence –Experiencing or witnessing destruction, death, injury, illness, disability, killing, torture, atrocities Loss –Family and friends –Physical capacity –Self: Identity, independence, confidence, role in family –Security: safety, education, job, finances –Home and social institutions/support –A future Threat of Violence or Loss

9. Reactions to Danger Physical –Fight or flight, ↑ heart rate, ↑ breathing, ↑ blood pressure, muscle tension, trembling Emotional –Fear, anxiety, aggression, strong emotions, hopeless, helpless, alert Psychological –Confusion, difficulty concentrating, numbness, disbelief Behavioral –Restless, acting without a plan, inaction, non-adherence to recommendations, over-dedication

10. Following Disaster Physical –↓sleep, ↑startle response, hyper-arousal, tension, fatigue, irritability, aches and pains, nausea, change in appetite, change in libido, low energy Emotional –grief, anxiety, guilt, anger, numbness, helplessness, hopelessness, shame, decreased interest, decreased pleasure, depressed mood Psychological –nightmares, poor concentration, unwanted memories, re- experiencing of disaster, confusion, disorientation, indecisiveness Behavioral –withdrawal, isolation, avoidance, numbing behavior (drugs/alcohol), distrust, conflict, irritability, social and occupational problems, decreased intimacy

11. Following Disaster Normal

12. Following Disaster Problematic: –Duration is too long –Social or occupational functioning impaired

13. Following Disaster Distress (normal reaction) Behavior Change (normal or problematic) Disorder (problematic, specific symptoms, illness) Distress Responses  Sense of vulnerability  Insomnia  Irritability, distraction  PTSD  Depression  Complex Grief  Smoking  Alcohol  Over dedication Center for the Study of Traumatic Stress

14. Following Disaster

15. Affected Groups Victims Responders Population at Large

16. Victims Ensure basic needs are met (food, water, shelter) Re-establish social structures and support services Promote community mobilization, cohesion, participation, psychosocial programs Avoid critical incident stress debriefings Employ Psychological First Aid (PFA) –Expert-consensus based approach –Not only for professionals –Look, Listen and Link Medical treatment for disorders

17. Psychological First Aid Core Principles 1.Safety 2.Calming 3.Connectedness 4.Self-Efficacy 5.Hope/Optimism

18. Responders Primary traumatic stress Vicarious traumatic stress Compassion fatigue Burnout Withdrawal, isolation, lack of support Mental disorders

19. How to Prevent Responders from Becoming Victims Selection Training Resiliency Clearly defined role Organizational support Adequate work/rest cycle Diet and exercise Connection to other workers, social support Opportunity to talk

20. Population Good Risk Communication –Clear message –Early information –Credible Sources –What the public should do / not do –Dispel rumors Social support for those who need it Return to normalcy

21. Psychological Timeline 1 to 3 Days -------------------TIME-------------------------------1 to 3 Years Warning Threat Pre-disaster “Heroic” Honeymoon (Community Cohesion) (Coming to Terms) Working Through Grief Reconstruction A New Beginning Disillusionment Trigger Events and Anniversary Reactions Impact Inventory Zunin/Meyers

22. Questions Questions?

23. Geoffrey J. Oravec, MD, MPH, MALD Capt, USAF, MC goravec@cdham.org 301-294-1470