Geoffrey J. Oravec, MD, MPH, MALD Capt, USAF, MC

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

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

3. What is a Disaster? • 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

4. What is a Disaster? Vulnerable Population x = Disaster Risk Hazard Preparedness

5. Disaster Trends Affected Disasters Killed

6. Types of Disasters • 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 • Smoking • Alcohol • Over dedication • Sense of vulnerability • Insomnia • Irritability, distraction • PTSD • Depression • Complex Grief 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 • Safety • Calming • Connectedness • Self-Efficacy • 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. Honeymoon(Community Cohesion) Reconstruction A New Beginning “Heroic” Pre-disaster Disillusionment Warning Threat (Coming to Terms) Working Through Grief Impact Trigger Events and Anniversary Reactions Inventory 1 to 3 Days -------------------TIME-------------------------------1 to 3 Years Zunin/Meyers Psychological Timeline

22. Questions Questions?

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