Doctors confront burst of mental health problems after disasters

Less than two days after a twister leveled much of Joplin, Mo., and killed more than 130 people, a tornado siren sounded again.

Many residents who were living in shelters because they lost their homes in the May 22 tornado cried and screamed at the thought of another storm.

"They just lost it. ... It was like being shell-shocked. It's hard to maintain one's emotional composure in that setting," said David Barbe, MD, a Mountain Grove, Mo., family physician and a member of the American Medical Association's Board of Trustees. He practices about 120 miles from Joplin and has administrative duties for some practices located near the southwest Missouri city.

Nearly everyone who experiences a traumatic event like a natural disaster will be affected psychologically in some way, mental health experts say. Symptoms can vary from sadness and difficulty sleeping to posttraumatic stress disorder. The severity and duration often depend on what an individual went through and lost.

Disaster planning tends to focus on responding to the immediate physical needs and injuries of victims. But experts say more must be done to address the mental health impact in the aftermath.

Physicians may encounter patients with severe reactions such as heart palpitations, vivid nightmares and hallucinations. Or they may see more common signs such as headaches and nausea.

Although many symptoms are temporary, doctors need to know how to identify them early and prevent them from escalating.

Mental health professionals also urge doctors to be cautious about prescribing medication to ease symptoms. They say drugs sometimes can hinder a person's ability to cope properly with a traumatic event.

"The goal is to help an individual make sense of their world being overturned. If one is overmedicated, that makes it much more difficult to do the psychological work of moving beyond the trauma," said Richard Shadick, PhD, director of the Pace University Counseling Center in New York City.

A tornado's impact

In Joplin, St. John's Regional Medical Center is a physical reminder of one of the nation's deadliest tornadoes. Winds of more than 200 mph left the structure uninhabitable. Six people in the hospital were killed -- five patients and one visitor. Elsewhere in the city of 50,000, businesses, homes and schools were reduced to rubble.

Mental health experts are working around the clock to treat residents. Dr. Barbe said primary care physicians in Joplin and neighboring communities also are seeing an increase in patients with mental health needs.

In the first 24 hours after a disaster, survivors often exhibit confusion, despair, disbelief and disorientation. The emotional distress often is compounded by concerns about safety and finding shelter.

In cases of terrorism, such as the Sept. 11, 2001, attacks, fear is a common response among victims, said Manasquan, N.J., psychologist Raymond Hanbury, PhD, a trauma expert. Some survivors develop acute stress disorder shortly after a traumatic incident, Shadick said. The condition can last up to a month and is characterized by anxiety, disorientation, and difficulty sleeping or eating.

"A lot of people have reactions [to trauma] that can be very distressing to them. What scares them is [the thought that they are] mentally ill. But a majority of people don't go on to develop mental illness," said Anthony Ng, MD, medical director of psychiatric emergency services at the Acadia Hospital in Bangor, Maine.

About 25% to 30% of victims of significant trauma develop PTSD, according to a Dec. 15, 2003, American Family Physician report. But traumatic stress specialist April Naturale, PhD, urged primary care physicians to be cautious about diagnosing disaster survivors with PTSD or another mental illness. Many times the symptoms are short-lived and should not be treated with medication, said Naturale, director of disaster services at the Mental Health Assn. of New York City.

"Our bodies are getting out the stress and the shock of a traumatic event by many of these symptoms, and [doctors] need to allow those patients to resolve on their own," Naturale said.

In some instances, however, emotional problems linger. A study of 283 children displaced by Hurricane Katrina in 2005 found that they were nearly five times more likely than a pre-Katrina national comparison sample to have "serious emotional disturbance." This mental health category is similar to PTSD and accounts for children's distress and social, behavioral and functional impairment.

To determine a patient's mental health following a disaster, physicians should ask about the patient's feelings, appetite and sleep pattern, Dr. Ng said. He also encourages doctors to inquire about patients' support systems, because isolated individuals have an increased risk of severe symptoms.

"Sometimes, the mere act of listening and helping patients prioritize [their needs] might be all that's needed," Dr. Ng said.

Among those most at risk for severe psychological effects are people with preexisting mental conditions and substance abusers. The trauma of a disaster can cause people with mental illness to become symptomatic and lead those with addictions to begin abusing alcohol or other drugs again.

Physicians should encourage patients with preexisting mental conditions to continue taking medication as prescribed and meeting with their mental health professionals if possible, experts say.

Red flags of serious symptoms include patients who isolate themselves, have recurrent vivid nightmares and who say they feel numb, Naturale said. In these instances, she said physicians should screen for PTSD. She said the disorder also should be considered if the individual's acute stress symptoms do not resolve within 30 days.

Primary care physicians can use the four-question Primary Care PTSD screen. The screen asks patients if in the past month they had nightmares about a particular experience, tried hard not to think about it, were constantly on guard, and felt numb or detached from others. A patient is considered to have the condition if he or she answers "yes" to any three items.

If left untreated, PTSD can become a chronic, disabling mental health disorder. PTSD patients, as well as those who are suicidal or feel too distressed to function, should be referred to mental health specialists, experts say.

Getting seen by such specialists can be difficult during a disaster, due largely to the national shortage of mental health professionals and the overwhelming need for their services during traumatic events.

Physicians' well-being

In Joplin, Dr. Barbe said treating victims with mental health needs has been challenging for physicians because doctors are struggling with many of the same concerns as their patients. About 80 of the city's doctors affiliated with St. John's had their practices disrupted due to the tornado, he said.

"The dilemma for physicians is that they have to deal with their own personal trauma at the same time they're trying to get their head around how to" best care for the survivors' medical needs, Dr. Barbe said.

Metairie, La., pediatrician Floyd Buras, MD, can sympathize with Joplin physicians.

His New Orleans practice was destroyed by Hurricane Katrina. All of his patients left the city and relocated elsewhere in Louisiana and to other states. Dr. Buras rebuilt his practice in a neighboring community, but he knows doctors who did not handle the storm's devastation as well.

"I had a good friend, a colleague, who committed suicide over it. A number of people just couldn't handle it," he said.

Health professionals can experience vicarious traumatization when working with a large number of people exposed to a distressing situation, Shadick said. In this condition, caregivers experience symptoms that are similar to those of the patients they are treating. Physicians also can develop compassion fatigue, which Shadick likened to doctors burning out.

To prevent these conditions, Naturale said health professionals need to exercise, get adequate sleep and take time off from work. She said they also should debrief with a colleague at the end of each day.

Doctors need to know when to give care and when to get it, Dr. Barbe said.

"If I had one message for physicians involved in a disaster," he said, "it would be to recognize when you need to be the receiver of care."