Mental health disaster response with Dr. Judith Milner

Judith R. Milner, MD, MEd, SpecEd, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about steps psychiatrists can take to address the mental health needs of people traumatized by a natural disaster, such as Hurricane Dorian survivors.

In This Week in Psychiatry, Katherine Epstein, MD, and Helen M. Farrell, MD, write about miracle cures in psychiatry. You can read the article online by clicking here or you can access the downloadable PDF by clicking here.

Time Stamps:

• This Week in Psychiatry (02:37)
• Interview with Dr. Milner (06:33)
• Dr. RK with Dr. Renee Kohanski (39:31)

Dr. Milner is a general and child and adolescent psychiatrist in private practice in Everett, Wash. She has traveled across the globe with various groups in an effort to alleviate some of the suffering caused by war and natural disaster.

Don't miss the "Dr. RK" segment by Renee Kohanski, MD, who discusses the extent to which people choose what is important and meaningful. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn.

Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

STAGES OF NATURAL DISASTERS

Devastation stage

• During the devastation stage, the primary objectives are giving basic first aid and attending to the sick, searching for those who are missing, and getting people safely into shelters.
• Psychological first aid (PFA) is the primary form of mental health treatment. PFA addresses basic needs by helping people find shelter, food, water; assisting with communication; reuniting families; and conducting case management to address acute needs.

Normalization stage

• The normalization stage continues for several months after the disaster and includes the honeymoon phase, in which people are grateful to have survived and the community unites to rebuild; and then the disillusionment phase, during which frustrations and hopelessness arise as communities and individuals realize the limits of disaster assistance.
• Psychiatric disorders are likely to develop during the normalization stage. Acute stress disorder (ASD) typically occurs 3-30 days after the event with cardinal symptoms such as hyperarousal, hypervigilance, and negative cognitions that affect relationships. Medical professionals should monitor for development of chronic disorders such as PTSD, major depressive disorder, and anxiety disorders. Prolonged stressors, such as living in a damaged home, increase the risk of depression and anxiety.
• Those with preexisting vulnerabilities – such as past traumatic experiences from physical, sexual, or emotional abuse; previous natural disasters; or other chronic stressors of poverty and medical illness – are at greatest risk of developing a trauma-related disorder after a natural disaster.
• The normalization stage is a critical period to use the "training the trainer" model. Because many locations do not have a surplus of mental health clinicians, psychiatrist volunteers can train local individuals to provide services. For example, mental health professionals can train the trainers to recognize symptoms of common psychiatric conditions and to provide basic treatment.
• Manualized therapies are useful but require in-depth training. Other simple modalities, such as deep breathing, visualization, and relaxation techniques, can be useful.

Acceptance stage

• During the acceptance stage, rates of persistent PTSD range from 25% to 40%.
• Ongoing therapy is helpful, especially group therapy, which is an effective use of resources. Facilitation of group therapy can be taught while training the trainers.
• If a mental health professional volunteers and participates in the training the trainers' model, there must be follow-up, which should include providing intellectual support and refresher courses, evaluating how training is being used, and checking up on patients/clients who have received services.

Predisaster advice: Do not go it alone. Affiliate with a group that has a plan, so that your presence on the scene does not add to the chaos.

Postdisaster advice:

• Be aware of compassion fatigue and take time away from volunteerism. Recognize signs of secondary traumatic stress.
• Counsel volunteers upon their return from the disaster site.

References

Substance Abuse and Mental Health Services Administration. Phases of disaster. Last updated 2018 Oct 1.

Pfefferbaum B et al. Practice parameter on disaster preparedness. J Am Acad Child Adolesc Psychiatry. 2013 Nov;52(11):1224-38.

World Health Organization. Psychological first aid: Guide for field workers. 2011.

National Child and Traumatic Stress Network. Psychological first aid online.

International Institute for Psychosocial Trauma. Clinical assessment of survivors of trauma.

U.S. Department of Veterans Affairs. PTSD: National Center on PTSD.

Compassion Fatigue Awareness Project.

Disaster Psychiatry Outreach.

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