Meg Barbor, MPH

October 25, 2017

NEW ORLEANS ― Psychiatrists play a major role in supporting community resilience after disaster. Now, in the wake of major disasters in Texas, Florida, Puerto Rico, and California, teamwork between clinicians and communities is more important than ever, experts say.

"My first experience with a disaster was Hurricane Katrina," Ben Springgate, MD, MPH, associate professor of clinical medicine at Louisiana State University Health in New Orleans, told delegates attending the Institute of Psychiatric Services (IPS): The Mental Health Services 2017 Conference.

"When Katrina occurred, there was a dramatic shift in reality. Hundreds of thousands of people were displaced, hundreds of thousands of housing units were destroyed, and people's lives were turned on end," he said.

In the immediate aftermath of Hurricane Katrina, people in New Orleans dealt with problems involving rebuilding, getting businesses up and running again, and making sure loved ones were cared for.

"But after the adrenaline rush and the initial grief of any disaster, particularly larger ones, there comes a point at which the stress has accumulated. People get tired and start to feel worn out. They start to run into roadblocks, and the daily tasks of getting up and recognizing there's still no grocery store in their neighborhood and their kid still has to be driven 10 miles to get to school because there are no buses ― all of these day-to-day things you come to appreciate as part of living in the US in the 21st century, they're not there anymore, and that accumulates," said Dr Springgate.

He noted that more than 40% of adults and children in the communities affected by Hurricane Katrina experienced prolonged symptoms of depression, anxiety, and posttraumatic stress disorder (PTSD), and this statistic is similar in communities affected by other major disasters.

"Many of us come from communities where psychiatry as a resource to help address mental health is limited. There aren't enough psychiatrists compared to the community need at baseline. And if you superimpose a disaster onto that, there becomes a problem," he said. After a disaster, existing challenges are exacerbated, and connections to healthcare providers may be lost. Large numbers of people are suddenly facing the biggest crisis they've ever dealt with, and this can lead to symptoms suggestive of potentially disabling conditions.

High Rates of Anxiety, Depression, PTSD

Bowen Chung, MD, MSHS, associate professor-in-residence in the Department of Psychiatry and Biobehavioral Sciences at the David Geffen School of Medicine at UCLA, Los Angeles, Calfornia, said that dealing with depression after disaster is especially challenging because the infrastructure that had been in place to address mental health problems no longer exists ― a fact that underlines the importance of community engagement.

"One of the first things that comes up in this type of work is that people don't want to call depression 'depression,' " he said. "They want to talk about resiliency and strength. Adapt language when necessary so as to engage community members and get them talking about what they're facing," he added.

"These interventions we develop to address things like depression are getting a lot of traction very quickly, because people know that if you don't improve depression outcome, individuals may be unable to manage other chronic illnesses and may have unnecessary hospitalizations and ER visits," he said. "But community engagement works."

After Hurricane Katrina, Dr Springgate and his colleagues worked with community partners to develop a nonprofit mental health infrastructure and training program called REACH NOLA (Resilience and Recovery in New Orleans).

They performed a rapid qualitative assessment in order to understand community perspectives, needs, priorities, and capacities, and they engaged scores of agencies, including clinical, neighborhood, and faith-based organizations. "We learned quickly and unexpectedly that, 9 months after the disaster, mental health was one of the greatest priorities on people's lists," he noted.

"And it wasn't just something that an epidemiologist identified ― 40% of the population suddenly dealing with depression, anxiety or PTSD ― people were writing about it in the op-ed columns and the newspapers. It was on the news at night and on radio talk shows. It was palpable and everywhere."

Nonclinical Partners Critical

They trained more than 400 providers ― physicians, therapists, psychologists, case managers, and community health workers ― and implemented a system of collaborative care that included nonclinical partners, such as neighborhood associations and churches. Through this effort, they were able to support more than 100,000 patients.

"The notion is that working with nonclinical partners to tackle community-level mental health and behavioral health needs is an opportunity for psychiatry to show leadership," he explained. "It's also an opportunity for psychiatry to recognize that there are other team members who can collaboratively do some of the work."

He advised that, after disaster, evidence-based, capacity-building care models that have been shown to work in distressed or underserved communities can be utilized and dispersed through working with established community partners that are still available and that are involved in recovery.

According to Dr Springgate, disaster resilience is about self-sufficiency, partnership, and ensuring a sense of social cohesion between community and clinical partners.

"Eight months after the hurricane, when there were only 11 practicing psychiatrists left in the city of New Orleans, you recognize that you have to try something new," he said. "And these evidence-based practices and opportunities for collaboration were what gave us hope and gave us the sense that we could help to make a difference in people's lives," he said.

"We have to recognize that we are not the only experts here," he continued. "The neighborhood association leaders who are speaking about depression, the community health workers who are knocking on doors and giving referral options for depression while also checking in on basic needs, each of these people has insights into their community and is a leader and able to contribute. We have to make sure that we're very cognizant of that."

Dr Springgate and Dr Chung have disclosed no relevant financial relationships.

Institute of Psychiatric Services (IPS): The Mental Health Services 2017 Conference. Presented October 20, 2017.

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