Integrating Integrating EthicalEthical Research and Research and Practice Practice

in in Disaster Mental HealthDisaster Mental Health

Peykan G. GökalpPeykan G. GökalpBakırkoy Research and Bakırkoy Research and

Training Hospital for Training Hospital for Psychiatry and NeurologyPsychiatry and Neurology

Istanbul - TurkeyIstanbul - Turkey

Main pointsMain points

Disaster studies from TurkeyDisaster studies from Turkey Overall conclusion of the studiesOverall conclusion of the studies ADEPSTEP, a services project on ADEPSTEP, a services project on

disaster mental healthdisaster mental health Some Q & A on ethics and disaster Some Q & A on ethics and disaster

research research Ethical evaluation of ADEPSTEP ( a Ethical evaluation of ADEPSTEP ( a

model)model)

Disaster and Mental HealthDisaster and Mental Health

Disasters strike the well being, Disasters strike the well being, infrastructure, economy and most of infrastructure, economy and most of all all mental healthmental health of the community of the community

Mental health services are not Mental health services are not taylored for disaster survivors and taylored for disaster survivors and working on the field.working on the field.

Studies before 1999Studies before 1999 Effects of the eathquake on the social structure of the Effects of the eathquake on the social structure of the

society society Örnek et al. (1971) BurdurÖrnek et al. (1971) Burdur ““PTSD in earthquake survivors” PTSD in earthquake survivors”

Veznedaroğlu et al. (1993) Erzincan ‘93Veznedaroğlu et al. (1993) Erzincan ‘93 ““Correlates of earthquake cognition and preparedness Correlates of earthquake cognition and preparedness

in a victimized population”in a victimized population”Rustemli & Karancı (1999) Erzincan ‘93Rustemli & Karancı (1999) Erzincan ‘93

““Dinar Earthquake and Expectations from Godot “ Dinar Earthquake and Expectations from Godot “ Aksit et al. 1997 Dinar ’95Aksit et al. 1997 Dinar ’95

““Preliminary report of stressor effects on adolescent Preliminary report of stressor effects on adolescent survivors of Dinar Earthquake”survivors of Dinar Earthquake” Sener at al. (1997)Sener at al. (1997)

The investigation of acute stress disorder after the The investigation of acute stress disorder after the 1998 Adana earthquake. 1998 Adana earthquake. Uguz et al. (2000) Adana ‘98Uguz et al. (2000) Adana ‘98

Disaster Studies in Turkey Disaster Studies in Turkey

1971 Burdur Earthquake (6.2)1971 Burdur Earthquake (6.2)

Effects of the earthquake on the social structure Effects of the earthquake on the social structure of the societyof the societyÖrnek et al. (1971):Örnek et al. (1971):

3 Psychiatrists made face to face interviews with 150 3 Psychiatrists made face to face interviews with 150 survivors in the first week after the disaster.survivors in the first week after the disaster.

Results: social classes moved closer, the feeling of Results: social classes moved closer, the feeling of solidarity increased.solidarity increased.

88 % felt confusion, 88 % felt confusion,

15 % stood still, 15 % stood still,

63 % participated in rescue work63 % participated in rescue work

Audio records were madeAudio records were made

1999 Marmara Earthquake (7.4)1999 Marmara Earthquake (7.4)

• Ayatan 2000Ayatan 2000• Dindar 2000 Dindar 2000 • Yucel et al. 2000Yucel et al. 2000• ADEPSTEP (Adapazarı) 2001ADEPSTEP (Adapazarı) 2001• Hacıoglu 2001 Hacıoglu 2001 • Unlugedik 2001Unlugedik 2001• Yigit 2000 GATAYigit 2000 GATA• Sezgin & Yuksel 2001Sezgin & Yuksel 2001• Tural et al. 2001Tural et al. 2001• Basoglu et al. 2002 Basoglu et al. 2002 • Karamustafalıoglu et al. 2002Karamustafalıoglu et al. 2002• Basoglu et al. 2003Basoglu et al. 2003• Özguler 2003Özguler 2003• Salcioglu et al. 2003Salcioglu et al. 2003

Risk factors for PTSDRisk factors for PTSD

Ayatan 2000Ayatan 2000 n=151n=151 ((72.8% 72.8% female, 27.2% male)female, 27.2% male)

20 (13.2%) 20 (13.2%) saved from the rubblessaved from the rubbles,, 38 (25.2%) 38 (25.2%) was woundedwas wounded, , 21 (13.9%) 21 (13.9%) lost at least one member of the familylost at least one member of the family

Risk factors: low education, rescuers, Risk factors: low education, rescuers, history of an anxiety disorder, history of an anxiety disorder,

PTSD predictorsPTSD predictors

Dindar 2000: 3 weeks after the eq, Dindar 2000: 3 weeks after the eq, n=n=283283 ( (61.5 %61.5 % female, female, 38.538.5 % male) % male)

Mean age: Mean age: 3232..6868 ±±1212..2222 The immediate physiologic responses The immediate physiologic responses

(tremor / trembling) to the eq were (tremor / trembling) to the eq were significantly related to PTSD significantly related to PTSD symptomatology.symptomatology.

The relationship between early phase The relationship between early phase PTSD symptoms and predicting factors PTSD symptoms and predicting factors

Ünlügedik 2001Ünlügedik 2001

N= N= 285 285 ((61.5 %61.5 % female, female, 38.5 %38.5 % male male ) ), , interviews were conducted in 3 wk. after interviews were conducted in 3 wk. after the eq. the eq.

Mean age: Mean age: 3232..6868 ±±1212..22 22 ““Gender (female) is the most powerful Gender (female) is the most powerful

predictor for symptom severity”predictor for symptom severity”

Comorbidity in PTSDComorbidity in PTSD

Tural et al. 2001Tural et al. 2001

• N= N= 76 (68.476 (68.4 %% female, female, 31.6 %31.6 % male) male)• Mean age:Mean age:41.58±11.2441.58±11.24• Severely traumatized populationSeverely traumatized population

44.7 %44.7 % saved from the rubbles, 9.2 saved from the rubbles, 9.2%% severely severely wounded, wounded, 23.7%23.7% lost a first degree relative, 22.4 % had lost a first degree relative, 22.4 % had a first degree relative with a psychiatric a first degree relative with a psychiatric disorder.disorder.

• 38.2 % had a comorbid disorder38.2 % had a comorbid disorder• 28.9 % had a secondary m. Depression28.9 % had a secondary m. Depression• Predictors for comorbidity: loss of a close rel, physical Predictors for comorbidity: loss of a close rel, physical

damage, being female, experiencing severe fear of damage, being female, experiencing severe fear of deathdeath

The natural course of PTSDThe natural course of PTSD

Karamustafalıoglu et al. 2003Karamustafalıoglu et al. 2003 a follow up study a follow up study

conducted in Avcılar- conducted in Avcılar- Istanbul.Istanbul.

99 422422 people screened in people screened in the first the first 3 3 months, months, 38.8 %38.8 % PTSD.PTSD.

1515 453453 people screened in people screened in thethe 6-8. 6-8. months post months post disaster, disaster, 23.823.8 %% P PTSTSD.D.

1515 597 597 was screened in was screened in the 1the 18-208-20. months, . months, 8.1 % 8.1 % had Phad PTSTSD.D.

The prevalence rate of PTSD The prevalence rate of PTSD decreased with time.decreased with time.

0

5

10

15

20

25

30

35

40

1st asses 2nd asses 3rd asses

PTSD %

Predictors of PTSD symptom severityPredictors of PTSD symptom severity

Salcıoglu et al. 2003 (J Nerv Ment Dis)Salcıoglu et al. 2003 (J Nerv Ment Dis) Prevalence rate of PTSD and Depression Prevalence rate of PTSD and Depression

was studied at was studied at 2020.. month after the eqmonth after the eq 586 586 were screened, who lived in a were screened, who lived in a

prefabricated villageprefabricated village 39 % 39 % had Phad PTSTSD, D, 18 %18 % had depression had depression PPTSTSD symptom severity was higher in D symptom severity was higher in

women, elderly, rescuers, who had a women, elderly, rescuers, who had a psychiatric history, who were saved from psychiatric history, who were saved from the rubble and who felt an overwhelming the rubble and who felt an overwhelming fear.fear.

PTSD in elderly disaster survivorsPTSD in elderly disaster survivors

Özgüler 2003Özgüler 2003 n=90n=90 5151 survivors( survivors(18-55 18-55 yo)yo) 39 39 survivors (survivors (>>60 yo)60 yo), , who fullfilledwho fullfilled

DSM lV DSM lV PPTSTSD criteriaD criteria The symptom severity and frequency The symptom severity and frequency

decreased with age, younger adults decreased with age, younger adults had more comorbid diagnoses.had more comorbid diagnoses.

Common features of the studiesCommon features of the studies

Focused on the prevalence of PTSDFocused on the prevalence of PTSD Most published data have follow-up Most published data have follow-up

assessmentsassessments Predictors for PTSD were discussedPredictors for PTSD were discussed Majority have unselected population Majority have unselected population

in the community as samplesin the community as samples Small number of research on Small number of research on

population from mental health population from mental health services.services.

Disaster studies with child survivors Disaster studies with child survivors after 1999after 1999

Berkem & Bildik 2001Berkem & Bildik 2001 Yorbik at al. 1999Yorbik at al. 1999 Laor et al. 2002 (Y.Yazgan)Laor et al. 2002 (Y.Yazgan) Alyanak et al. 2000Alyanak et al. 2000 Wolmer et al. 2003 (Y. Yazgan)Wolmer et al. 2003 (Y. Yazgan) Yorbik et al. 2004Yorbik et al. 2004

Child & adolescent studies:Child & adolescent studies:Overall conclusion Overall conclusion

The perception and response to trauma The perception and response to trauma differs according to developmental factors.differs according to developmental factors.

DSM-IV criteria are insufficient to diagnose DSM-IV criteria are insufficient to diagnose PTSD for preschool childrenPTSD for preschool children

Sleep disorders and pains were more Sleep disorders and pains were more frequent with physical traumafrequent with physical trauma

The duration of staying in the rubbles The duration of staying in the rubbles caused emotional isolationcaused emotional isolation

Trained teachers can help MH Trained teachers can help MH professionals in determining child professionals in determining child survivors of disaster who needed helpsurvivors of disaster who needed help

Emirdag Prefabricated VillageEmirdag Prefabricated VillageAdapazarıAdapazarı

Population:3000Population:3000 Number of houses: Number of houses:

425425 Area of a house: Area of a house:

36m36m22

Social service Social service houses: 10houses: 10

Target population of EmirdagTarget population of Emirdag

• PoorPoor• UneducatedUneducated• With no regular work and incomeWith no regular work and income• Mostly without permanent houseMostly without permanent house• With high expectations of social With high expectations of social

solutionssolutions• With problematic health services useWith problematic health services use

ADEPSTEPADEPSTEPYüksel, Sercan, Sezgin, Gökalp 2005Yüksel, Sercan, Sezgin, Gökalp 2005

PSYCHOLOGICAL SUPPORT, SCREENING AND PSYCHOLOGICAL SUPPORT, SCREENING AND TREATMENT PROJECT FOR POST-DISASTER MENTAL TREATMENT PROJECT FOR POST-DISASTER MENTAL

HEALTH PROBLEMS IN ADAPAZARIHEALTH PROBLEMS IN ADAPAZARI

ObjectivesObjectives: inadequate mental health services in : inadequate mental health services in the area.the area.

Supporting mental health facilities in the areaSupporting mental health facilities in the area

Identifying risk groups for PTSD and other Axis Identifying risk groups for PTSD and other Axis I disorders (Screening the unselected I disorders (Screening the unselected traumatized population)traumatized population)

Treatment and counsellingTreatment and counselling Follow-up of those who need treatment for 1 Follow-up of those who need treatment for 1

yearyear

ADEPSTEPADEPSTEP

Project team: 14 volunteer psychiatrists and Project team: 14 volunteer psychiatrists and psychologists from two institutions in psychologists from two institutions in IstanbulIstanbul

Support of NGO: Adapazarı Earthquake Support of NGO: Adapazarı Earthquake Survivors OrganizationSurvivors Organization

Scientifically Supported by:Scientifically Supported by:Psychiatric Association of TurkeyPsychiatric Association of TurkeyESTSSESTSSTMATMA

Financially Supported by: ACT NetherlandsFinancially Supported by: ACT Netherlands

ADEPSTEPADEPSTEP

Screening and Evaluation Instruments:Screening and Evaluation Instruments:• Eartquake History Inventory (Sezgin&Yüksel, Eartquake History Inventory (Sezgin&Yüksel,

2000)2000)• Posttraumatic Diagnosis Scale (Foa 1995 )Posttraumatic Diagnosis Scale (Foa 1995 )• Impact of Events Scale-R(Horowitz et al. 1979; Impact of Events Scale-R(Horowitz et al. 1979;

Marmar 1996)Marmar 1996) Diagnosis: DSM-IVDiagnosis: DSM-IV Follow-up Instruments:Follow-up Instruments:

• CGICGI• HRSD, HRSAHRSD, HRSA

ADEPSTEPADEPSTEP

The screening : at 8The screening : at 8thth month after the month after the earthquake.earthquake.

Those who were identified at risk were Those who were identified at risk were interviewed again by a mental health interviewed again by a mental health professional for diagnostic purposes and professional for diagnostic purposes and treatment.treatment.

Those who needed medication were Those who needed medication were followed –up for medication. Those who followed –up for medication. Those who were included in group therapy had were included in group therapy had sessions every two weeks.sessions every two weeks.

ADEPSTEPADEPSTEP

350 people were screened350 people were screened 71 % (n=247) were women71 % (n=247) were women 29 % (n=103) were men29 % (n=103) were men Age: 37.45 (Age: 37.45 (±±12.8) R:16-8012.8) R:16-80 Low incomeLow income Low-middle education statusLow-middle education status Married, with average 2 childrenMarried, with average 2 children Housewives (63.7%)Housewives (63.7%)

ADEPSTEPADEPSTEPRisk Factors for PTSD Risk Factors for PTSD

Being rescued from the rubblesBeing rescued from the rubbles Being injuredBeing injured Having a close other died near Having a close other died near

her/himselfher/himself Having a close relative who died in Having a close relative who died in

the earthquakethe earthquake Participating in rescue effortsParticipating in rescue efforts

ADEPSTEPADEPSTEP

59.7 % had PTSD59.7 % had PTSD Those with medium and serious Those with medium and serious

symptom severity were 61.8 %symptom severity were 61.8 % Those with medium and serious Those with medium and serious

functional impairment were 57.1 %.functional impairment were 57.1 %.

Disaster mental health services in the fieldDisaster mental health services in the field“homework” questions !“homework” questions !

Is research needed on disaster mental Is research needed on disaster mental health ? health ? Research is needed to understand the nature of Research is needed to understand the nature of the reactions to disaster and the efficacy of the the reactions to disaster and the efficacy of the interventionsinterventions

Did research emerge from these services?Did research emerge from these services? What happened to surveys on the first What happened to surveys on the first

days of the disaster?days of the disaster? What happened to unpublished data and What happened to unpublished data and

information ?information ? Who publishes the Experiences?Who publishes the Experiences?

WPA Disasters and Mental HealthWPA Disasters and Mental Health

More QuestionsMore Questions

Are disaster survivors eligible for IC ?Are disaster survivors eligible for IC ?

Is the decisional capacity of survivors impaired?Is the decisional capacity of survivors impaired?

Some survivors might have an impaired decisional Some survivors might have an impaired decisional capacity due to the effects of acute stress. capacity due to the effects of acute stress. Physical trauma, general medical instability might Physical trauma, general medical instability might worsen the situation, but cannot be generalized worsen the situation, but cannot be generalized (Rosenstein 2004).(Rosenstein 2004).

The method of assessment for decisional capacity The method of assessment for decisional capacity should be statedshould be stated (Yüksel 2005). (Yüksel 2005).

Some More Questions !!Some More Questions !!

Are disaster survivors a “vulnerable” Are disaster survivors a “vulnerable” population?population?• No definite definition of vulnerability in No definite definition of vulnerability in

medical ethics.medical ethics.• Vulnerability increases if social status, sense of Vulnerability increases if social status, sense of

power, education level decrease.power, education level decrease.• Helsinki Declaration: “ some groups of people Helsinki Declaration: “ some groups of people

are more prone to be damaged from medical are more prone to be damaged from medical research, therefore these people deserve more research, therefore these people deserve more protection and caution”protection and caution”

Disaster survivors might be more vulnerable in Disaster survivors might be more vulnerable in the acute phase.the acute phase.

The ethical evaluation of The ethical evaluation of ADEPSTEP IADEPSTEP I

The survey was planned as a services project, The survey was planned as a services project, focusing on the needs of the affected focusing on the needs of the affected population.population.

As stated in the Helsinki Declaration (WMA) a As stated in the Helsinki Declaration (WMA) a high risk disadvantaged group who had no other high risk disadvantaged group who had no other opportunity for treatment / professional help opportunity for treatment / professional help was selected. was selected.

DEP-DER ( NGO formed by the earthquake DEP-DER ( NGO formed by the earthquake survivors of the area) was included and survivors of the area) was included and consulted in every step of the project. consulted in every step of the project.

The members of the staff were chosen from The members of the staff were chosen from those who were experienced on trauma field those who were experienced on trauma field work.work.

Yüksel 2005 (in press)Yüksel 2005 (in press)

ADEPSTEP (ethics) IIADEPSTEP (ethics) II Subjects who volunteered after the Subjects who volunteered after the

introductory meeting and had full introductory meeting and had full capacity for informed consent were capacity for informed consent were included.included.

Those included were given clear Those included were given clear information on the process of information on the process of interviewing and treatment options.interviewing and treatment options.

It was observed that illiterate people It was observed that illiterate people were confused with signing IC forms and were confused with signing IC forms and caused worry and suspicion. caused worry and suspicion.

The subjects had the right to exclude The subjects had the right to exclude themselves from the project at any step.themselves from the project at any step.

ADEPSTEP (ethics) IIIADEPSTEP (ethics) III

The calls for interviews were made by The calls for interviews were made by DEP-DER which is an NGO with no DEP-DER which is an NGO with no relation with official authorities. relation with official authorities.

Local resources were not used for any Local resources were not used for any need of the staff or the project. need of the staff or the project.

The confidentialty issue was given The confidentialty issue was given utmost importance although there were utmost importance although there were practical difficulties. The charts were practical difficulties. The charts were kept in Istanbul and carried for every kept in Istanbul and carried for every visit. visit.