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Disaster-Related Physical and Mental

Health: A Role for the Family Physician


JOHN R. FREEDY, M.D., PH.D., and WILLIAM M. SIMPSON, JR., M.D.
Medical University of South Carolina, Charleston, South Carolina

Natural disasters, technologic disasters, and mass violence impact millions of persons each year. The use of
primary health care services typically increases for 12 or more months following major disasters. A conceptual
framework for assist- ing disaster victims involves understanding the individual and environmental risk factors
that influence post-disaster physical and mental health. Victims of disaster will typically present to family
physicians with acute physical health problems such as gastroenteritis or viral syndromes. Chronic problems
often require medications and ongoing primary care. Some victims
may be at risk of acute or chronic mental health problems such
as post-traumatic stress disorder, depression, or alcohol abuse.
Risk fac- tors for post-disaster mental health problems include
previous mental health problems and high levels of exposure to
disaster-related stresses (e.g., fear of death or serious injury,
exposure to serious injury or death, separation from family,
prolonged displacement). An action plan should involve adequate
preparation for a disaster. Family physicians should educate

ILLUSTRATION BY MARK SCHULER


themselves about disaster-related physical and mental health
threats; cooperate with local and national organizations; and make
sure clinics and offices are adequately supplied with medications
and suture and casting material as appropriate. Physicians also
should plan for the care and safety of their own families. (Am
Fam Physician 2007;75:841-6. Copyright © 2007 American
Academy of Family Physicians.)

T
For a recent commentary he American Red Cross defines a common events that affect millions of per-
on this topic, please
see Swain GR, Burns K.
disaster as involving 100 or more sons annually; (2) with more persons
Emergency response: persons, 10 or more deaths,
1
or an living in disaster-prone areas and
increased tech-
physician training and appeal for assistance. Qualifying nologic complexity, it is expected that the
obligations. Am Fam events include natural disasters (e.g., hurri- risk and impact of disasters will increase in
Physician 2007;75:401-5
(http://www.aafp.o rg/
canes, earthquakes, floods, tornadoes), tech- future years; and (3) disasters are associated
afp/20070201/curbside. nologic disasters (e.g., nuclear or industrial with a variety of adverse physical and
html). accidents), and mass violence (e.g., terrorist mental health effects that can range from
attacks, shooting sprees). The annual world- mild and transient to severe and chronic.4
wide impact of disasters is substantial, with Family physicians are well suited to
an average of more than 500 incidents address the physical and mental health
impact- ing 80 million persons, displacing needs of disaster victims. Disaster exposure
5 million from their homes, seriously increases primary health care use for 12
injuring 74,000, and killing 50,000.2 months or more after the event.5 More
Although most large- scale disasters occur importantly, the acute and chronic physical
in developing countries, events such as and mental health issues that most
Hurricane Katrina in 2005 and the commonly occur after a disaster are within
September 11 terrorist attacks in 2001 are the scope of practice for family physicians
reminders that the United States is not and other board-certified primary care
immune to large-scale disasters.3 physicians.3,4,6-8
Years of research and applied practice
have produced a consensus about the vul- Risk Factor Model
nerability of the U.S. population to disasters. Table 1 presents a risk factor model for post-
Accepted facts include: (1) disasters are disaster adjustment.4 Research supporting
Dow nloaded from the American Family Physician Web site at w w w .aafp.org/afp. Copyright © 2007 American Academy of Family Physicians. For the private, noncommercial
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74 American Family Physician www.aaf p.org/afp Volume 75, Number 6 ◆ March 15,
2007
Disaster-Related Health
or social
SORT: KEY RECOMMENDATIONS FORsupport before
PRACTICE disaster [PTSD]) that can
the result in an impact post-disaster
Evidence
Clinical recommendation rating References
inability to response.10 Less
cope effec- intensely stress- ful life
Disaster victims with high levels of disaster C 4, 13, tively after events (e.g., financial
exposure should be monitored for the 15
the disaster. or marital problems)
possible emergence of post-traumatic stress
disorder, depression, or alcohol abuse.
In general, existing one year before
Mental health screening measures should C 27-32
ethnic disaster exposure have
be used to efficiently and accurately minority been associated with
identify adults who may be experiencing status and increased physical and
mental health problems following a lower income psychological symptom
disaster. have been reports.9,10
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-
quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual
associated In terms of mental
thispractice,
modelexpert is briefly
opinion, or case series. For information about the SORT evidence with poorer health, a history of pre-
rating system, see
summarized topageorient
789 or h tt p : / / w w w . a a f p . o r g / a f p s o r t . x m l . post-disaster disaster symptoms can
family physi- cians to physical and predict the presence of
these risk factors. When mental well- post-disaster symptoms.
clinically evaluating being.9 Also, persons with pre-
persons after a disaster, Although disaster mental health
family physicians should being histories are more likely
con- sider these married to display post-disaster
individual and appears to mental health problems
environmental risk help men, a including PTSD.8
factors to assess potential married Predictors of effective
impact on patients’ woman may coping can help triage
physical and mental experi- ence less- needy patients.
health. poorer post- Coping refers to
A person’s response disaster cognitive and behav-
to a disaster is adjustment if ioral abilities to solve
determined by her marital problems, manage
demographic and status results emotions, or disengage
socioeconomic factors, as in her giving from difficult problems
well as the person’s out more or emotions.11 In
pre-disaster mental health social general, successful coping
and the extent of his or support than is characterized by
her social support before, she flexibility, creative
during, and after the receives.4-7 thinking, willingness to
event. Regarding Pre- try new
demographic factors, disaster life things, action
children typically display events also orientation,
emotional distress when may have an working
family conflict occurs; impact on coopera-
middle-age adults post-disaster tively with
experience psychological physical and others, and
and physical problems mental the ability to
when a disaster makes it health. tolerate
impossible to meet Exposure to frustration or
responsibilities4,6-8; and traumatic other strong
older adults most often events has emotions.6,7,12
display post-disaster been associated with a The impact
physical and mental range of mental health of pre-disaster
health problems when problems (e.g., post- social sup-
limits on income, health, traumatic stress disorder port on post-
March 15, 2007 ◆ Volume 75, Number www.aaf p.org/afp American Family Physician 75
6
history;
Risk Factor Model for social support; traumatic and other
Post-Disaster
Adjustment* stressful life events
Within-disaster Deaths; experience of pain and horror; family
separation (including death); perceived
life threat; property loss; relocation and
displacement; serious injury

*—This model documents risk factors that can be used to roughly stratify risk level
disaster
for post-disaster comfortable
physical and mental health problems. Family physicians should keep
these individual and environmental
well-being is risk factors in in
mind tactfully,
when clinically evaluating
disaster victims.
complex. directly, and
Adapted with permission from Freedy JR, Resnick HS, Kilpatrick DG. Conceptual frame-
Generally, privately
work for evaluating disaster impact: implication for clinical intervention. In: Austin LS.
Responding tovictims’ asking
Disaster: A Guide for Mental Health Professionals. 1st ed. Washington,
D.C.: Americanpost-disaster
Psychiatric Press, 1992:6. patients
adjustment about
can be exposure to
improved if within-
they disaster
perceive that mental health
they are risk factors.
supported, if
they receive
more
support than
they give, or
if they are
embedded in
a healthy
social
network.6,7
Within a
disaster,
exposure
has
objective
(e.g.,
serious
injury,
death) and
perceived
(e.g.,
sensing
threat to
life)
elements.
High levels
of disaster
exposure
increase the
risk of
developing
PTSD or
other severe
men- tal
health
problems
following
the disas-
ter.4 Family
physicians
must be

76 American Family Physician www.aaf p.org/afp Volume 75, Number 6 ◆ March 15,
2007
Disaster-Related Health

March 15, 2007 ◆ Volume 75, Number www.aaf p.org/afp American Family Physician 77
6
Common Post- example, a disaster may of medica- tion and
Somatic complaints
Disaster Health exacerbate a chronic medical supplies may be
without organic cause,
Outcomes health condition such as sufficient. Depending on
sometimes described as
The probability of a diabetes or congestive the degree to which the
medically unexplained
particular post-disaster heart failure (CHF), with disaster has impacted
physical symptoms, are
physical or mental health worsening physical com- munity
common following a
condition varies health contributing to the infrastructure, such
disaster. These
according to the time development or assistance may be
unexplained symptoms
since the disaster onset. exacerbation of required as part of the
also are associated with
It is helpful to divide depression. The reverse intermediate or even
mental health prob- lems
the post-disaster time direction of causality is long-term phase of post-
such as depression, PTSD,
frame into acute (less possible, with mental disaster adjustment.
and other anxiety disor-
than one month), health problems resulting ders.26 Family physicians
intermediate (one to 12 in poorer health main- should increasingly
months), or long-term tenance efforts and consider a mental health
(i.e., chronic; longer than deterioration in chronic explanation for vague,
12 months) phases. health problems. unexplained physi- cal
Another way to view symptoms as time since
PHYSICAL HEALTH
the post-disaster time OUTCOMES the disaster increases.
frame is in terms of the
Table 24-9,18-26 presents MENTAL HEALTH
potential to experience a
common post-disaster OUTCOMES
series of chronic low-
health problems. Physical Most patients with post-
level stresses that may
problems fall into four disaster mental health
overwhelm coping
categories: problems had similar
resources.4,8,13-16 Family
(1) acute injuries; (2) problems before the
physicians can be key
acute problems; (3) disaster occurred. In
agents in lessening post-
chronic prob- lems; and such cases, the role of the
disaster physical and
(4) medically unexplained family physician includes
mental health reactions.
physical symptoms. More the provision of
Key points include
than one half of acute medication refills,
providing information,
post-disaster health issues supportive counseling,
remaining empathic,
are illnesses (e.g., self- and appropriate referrals
encouraging victims to
limited viral syndromes, when indicated and
seek and accept
gastroenteritis).20-24 feasible.
assistance, advocating
Approximately one fourth
self-determination to the
of acute post-disaster
extent feasible, reminding
health complaints are
persons of how they may
injuries (e.g., cuts,
have successfully coped
abrasions, sprains,
with previous troubles,
fractures). Other acute
and repeat- edly
post-disaster health issues
checking on disaster
include routine items such
victims for up to 12
as medication
months (or longer for
refills, wound checks, and
more severely devastating
splinting.19
events).17
It is common for
Physical and mental
disaster victims to require
health effects of disasters
assistance in the
often coexist. In some
management of chronic
instances, physical
health problems (e.g., dia-
problems may increase
betes, hypertension,
the probability of mental
CHF). Simple provision
health problems. For
78 American Family Physician www.aaf p.org/afp Volume 75, Number 6 ◆ March 15,
2007
TABLE 2
Common Post-Disaster Health Problems

Mental health
Disaster-Related Health
Acute responses18
Examples: Cognitive dysfunction or distortion;
dysfunctional interpersonal behaviors; emotional
lability; nonorganic physical symptoms
Chronic problems4,6-8
Examples: Alcohol abuse or dependence; depression;
interpersonal violence; PTSD or other anxiety
disorders; schizophrenia or other severe chronic
disorders
New-onset mental health problems6-8
Examples: Acute stress disorder possibly evolving
to PTSD; alcohol abuse or dependence;
depression; interpersonal violence
Physical health
Acute injuries19
Examples: Cuts or abrasions; fractures; motor vehicle
crashes; occasional self-inflicted wounds; sprains or strains
Acute problems20-24
Examples: Gastroenteritis or dehydration; head lice;
pulmonary problems; rashes; rodent-borne illness; self-
limited viral syndrome; toxic exposures; vector-borne
illness
Chronic problems5,9,20,25
Examples: Congestive heart failure; diabetes;
hypertension; pulmonary problems (e.g., chronic
obstructive pulmonary disease, acute bronchitis, asthma)
Medically unexplained physical symptoms26
Examples: Fatigue; gastrointestinal complaints; headaches;
other generally vague somatic complaints without clear
organic etiology

PTSD = post-traumatic stress disorder.


Information from references 4 through 9, and 18 through 26.

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serious injury, or four-step disaster
Acute post-disaster exposure to death. preparation plan so that
psychological distress A two-stage mental when disasters happen,
includes emotional health screening process is family physicians are able
lability; negative recom- mended. If a to turn their collective
emotions; cognitive dys- disaster victim is thought knowledge and skills into
function and distortions to be at high risk because compassionate and
(e.g., reduced concentra- of mental health history or competent action. This
tion, confusion, within-disaster expe- plan includes education,
unwanted thoughts or riences, that person should linking up with other
memories); physical be asked directly about organizations, logistical
symptoms (e.g., expo- sure to toxic preparation, and personal
headaches, tension, stressors (Table 34,6,7). If preparation.
fatigue, gastrointestinal initial screening suggests
upset, appetite changes); heightened mental health
and behav- iors that risk, the person should be
negatively affect asked further symptom-
interpersonal relationships based screening questions.
(e.g., irritability, distrust, The authors recommend
withdrawal, being overly using the following
con- trolling). For most screening questionnaires:
persons, acute a two-item patient health
psychological distress questionnaire for
will resolve within weeks depression (PHQ-2; 96
to several months, but it percent sensitivity; Table
can persist for up to one 4)27; a four-item primary
year. Distress tends to care PTSD screen (PC-
resolve as victims are PTSD [this test can be
able to reliably meet their viewed at
basic needs.18 http://www.ncptsd.va.gov/
More severe new-onset ncmain/
mental health problems assessment/ptsd_screening.
can occur, with the jsp]; 78 percent
presentation ranging sensitivity)28; and the TABLE 4
EDUCATION
Patient Health Questionnaire
from obvious to subtle. four-item CAGE Depression
Family physicians Screening*�
should
The most common post- questionnaire for alcohol educate themselves
disaster mental health abuse (75 to 97 percent How often over the past two weeks have yo
thoroughly about
e ither of the disaster-
following problems:
problems appear to be sensitivity).29-32 Relatively related physical and in doing things
depression, PTSD, and Having little interest or pleasure
high sensitiv- ity rates mental healthdepressed,
Feeling down, threats.or hopeless?
other anxiety disorders.8 suggest that very few There are many articles
Increases in alcohol or people with post-disaster and books available.6-8,33-36
drug abuse and domestic mental health problems *�Yes�versus o�response format, with yes = 1
Many Web sites also
of 1 is a positive screening result with a sensitivity o
or interpersonal violence will be missed by provide information aboutwith 0 = not at all;
�Four-point response format,
also have been noted.6,7 screening (i.e., low false- disaster-related
= mo re than one half resources
of the days; 3 = nearly every
Family physicians negative rate). Positive mor e is a positive screening result with a sensitivit
and service opportunities
should consider screening results should (Table 5). from reference 27.
Information
screening for common be followed up with All physicians should
mental health problems additional diagnostic inter- know about threats that
among vulnerable views and intervention as may impact a
populations, such as appropriate.25,33-35 community, including
persons with a history of bioterrorism, terrorism,
mental health issues, Disaster Preparation
and mass casualty
perceived life threat, The authors propose a events. Physicians within
80 American Family Physician www.aaf p.org/afp Volume 75, Number 6 ◆ March 15,
2007
certain geo- graphic
regions also should
educate themselves
regard- ing natural
disaster events
particular to their area.
LINKING

Many opportunities
exist to proactively
apply profes- sional
knowledge and skills
by becoming involved
in existing disaster
preparedness efforts.
Because the scope of
many disasters exceeds
local health care
capacity, it is

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Disaster-Related Health
TABLE 5
Internet Resources for Disaster Services and Disaster-Related Health Materials

Organization Web address Comment

82 American Family Physician www.aaf p.org/afp Volume 75, Number 6 ◆ March 15,
2007
American Academy of http://www.aafp.org Type “disaster response” into the search function to obtain a
Family Physicians (AAFP) listing of AAFP-related resources, which include fact-based
articles, training courses, and service opportunities
American Medical http://www.ama-assn.org Type “disaster response” into the search function to obtain a
Association (AMA) listing of AMA-related resources, which include training courses,
information about the health impact of disaster, summaries of
current AMA disaster activities, and other Web site links
American Red Cross http://www.redcross.org “Disaster services” link provides full access to Red Cross disaster
activities, which include related news stories and tips
on preparedness and coping with disasters
Centers for Disease Control http://www.cdc.gov “emergency preparedness and response” link provides health
and Prevention information on a full range of disasters; useful handouts
include helping families cope with the stress of relocation, tips
for talking about disasters, and self-care tips for coping with
National Center for Post- stress
traumatic Stress Disorder
http://www.ncptsd.va.gov Comprehensive list of clinical and research resources, including
United Way of America handouts to assist in working with disaster victims of all
and Alliance for
ages http://www.211.org This site and the associated 2-1-1 phone number service
Information and Referral
approximately 193 million Americans (more than 65 percent of the
Systems
population) in 41 states; they provide information and referrals
to persons needing help and persons wanting to provide help

important for family physicians to become embedded in same physical and mental health outcomes faced by
organizations that are most likely to be called on to meet other victims. On the other hand, physicians will want to
post-disaster community health needs. continue their medical practice for practical and altru-
Opportunities at a local or state level include disas- istic reasons. It is important to seek a balance between
ter response teams or planning committees at local taking care of oneself and one’s family versus taking care
hospitals, county and state medical societies, and local of patients.
and state health departments. To find opportunities Family physicians should be prepared to work with
at a national level, contact the medical organization of other health care professionals in the community
the affected states (who are often looking for outside to share the collective load in meeting post-disaster
help), the American Academy of Family Physicians, the health needs; such partnerships should be established
American Medical Association, the Centers for Disease well in advance of a disaster. The physicians in a com-
Control and Prevention, or other national-level orga- munity should be prepared to reach out to and accept
nizations. The American Red Cross and a variety of assistance from health care professionals outside of the
religious denominations and organizations also have community as well.
national disaster-response activities.
The authors thank William J. Hueston, M.D., and Clive D. Brock, M.B.,
LOGISTICAL PREPARATION Ch.B., for assistance with the manuscript.

Within each organizational response unit (e.g., clinic,


hospital, community health center), a several-week sup- The Authors
ply of frequently needed items should be available JOHN R. FREEDY, M.D., Ph.D., is an assistant professor in the
(e.g., medications for common medical and psychiatric Department of Family Medicine at the Medical University of South
Carolina in Charleston and the director of behavioral science curriculum
problems; suture, splint, and casting materials; educa- for the Trident/Medical University of South Carolina Family Medicine
tional materials). Outside sources of help are typically Residency Program in Charleston. Dr. Freedy received his doctorate in
unavailable or unreliable for several weeks to one month clinical psy- chology at Kent State University in Kent, Ohio, and
after a disaster, so the availability of local health care completed a National Institute of Mental Health fellowship in violence
and traumatic stress. He received his medical degree and completed a
resources is crucial to community well-being. family medicine residency at the Medical University of South Carolina.
PERSONAL PREPARATION WILLIAM M. SIMPSON, JR., M.D., is a professor of family medicine, the
director of public health and public service activities, and the director of
Family physicians who practice within disaster-stricken the South Carolina Agromedicine Program in the Department of Family
communities have a dual role. As disaster victims, Medicine at the Medical University of South Carolina. Dr. Simpson
physicians and their families will be vulnerable to the received his medical degree and completed a family medicine residency

March 15, 2007 ◆ Volume 75, Number www.aaf p.org/afp American Family Physician 83
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Disaster-Related Health
victims speak: part empirical literature, with
at the Medical University of II. Summary and implications implications for intervention. 17. U.S. Department of Veterans
of the disaster mental health U.S. Department of Veterans Affairs. effects of traumatic
South Carolina. He has
research. Psychiatry Affairs. Accessed February stress in a disaster situation.
practiced clinical medicine in
2002;65:240-60. 20, 2006, at: http:// www. A National Center for PTSD
military and civilian settings.
8. Norris FH, for the Dartmouth ncptsd.va.gov/ncmain/ncdocs/ fact sheet. Accessed
Address correspondence to Medical School and National fact_shts/fs_resources.html. February 20, 2006, at:
John R. Freedy, M.D., Ph.D., Center for PTSD. Range, http://www.ncp tsd.va.gov/nc
Trident/MUSC Family Medicine magnitude, and duration of the main/ncdocs/
Residency, 9298 Medical effects of disasters on mental fact_shts/fs_effects_disaster.
Plaza Dr., Charleston, SC health: review update 2005. html.
29406 (e-mail: Accessed December 12, 2006, 18. Young BH, Ford JD, Watson
freedyjr@musc.edu). Reprints at: PJ. Survivors of national
are not available from the http://www.redmh.org/researc disasters and mass violence.
authors. h/general/effects.html. A National Center for PTSD
9. Sanders S, Bowie SL, Bowie fact sheet. U.S. Department
Author disclosure: Nothing to YD. Lessons learned on forced of Veterans Affairs.
disclose. relocation of older adults: the Accessed February 20, 2006,
impact of Hurricane Andrew on at: http://www.ncptsd.
health, mental health, and va.gov/ncmain/ncdocs/fact_s
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