Disaster Mental Health in the Military Treatment Facility Setting

LCDR Brian Lees, Clinical Psychologist

HSO USPHS

“I have no financial or other significant relationship with any manufacturer of any product or organization I intend to discuss”

Disclosure

At the end of this presentation, attendees will have a better knowledge of 1. gain knowledge about DODI 6200.03 2. develop a basic understanding of

triage/assessment and early intervention treatment principles

3. discover important in-depth resources

Objectives

“Public Health Emergency Management within the DoD.”

3rd version: Incorporating Change 2, Effective October 2, 2013

DODI 6200.03

Defines what constitutes a “public health emergency”

Created the position of Public Health Emergency Officer

Third revision, mandates every installation has a Disaster Mental Health Response Team.

WHY?

DODI 6200.03

Galea, Nandi, & Vlahov (2005)“Studies conducted in the aftermath of disasters during the past 40 years have shown that there is a substantial burden of PTSD among persons who experience a disaster.” prevalence of PTSD among

direct victims of disasters is 30–40% rescue workers is approx 10–20% the general population is approximately 5–10%“PTSD is persistent for a few years after the disaster among victims with early PTSD onset.”

Norris et. al, (2002) review of 160 samples of disaster survivors also found a substantial minority also develop PTSD, MDD, substance abuse, and medical problems

Disasters can lead to PTSD and other disorders

Community hospital near WTC buildings was inundated by non-injured but psychologically distressed people (Wang, 2005)

Impact on the MTF

Alleviation of current suffering and prevention of long-term conditions such as PTSD, MDD, substance abuse that lead to significant social and occupational dysfunction

Objective of Disaster Mental Health

h. Establishes DoD policy for Disaster Mental Health Response (DMHR) and the roles and responsibilities of DMHR teams. (p.1)

DODI 6200.03 Purpose

k. Every DoD installation will have access to a DMHR team and disaster mental health (DMH) services in the event of an all-hazards incident. (p.5)

Brings up issues of local vs. non-local response (e.g. Navy SPRINT deploys out of Naval Medical Center San Diego)

DODI 6200.03Policy

a. Military Commanders. The Military Commanders shall: (12) Ensure DMH services are available through a DMHR team in response to an all- hazards incident by: (a) Appointing a licensed mental health provider as the DMHR

team lead, who is trained in disaster mental health services, and who has overall responsibility for DMHR team training and service implementation.

(b) Integrating DMH preparedness and response with other DoD installation and military command emergency response plans.

(c) Entering into agreements, as needed, with other installations, Reserve units, National Guard units, and/or civilian providers for DoD installations to ensure access to a DMHR team when the personnel and resources necessary to form a DMHR team are not present on a DoD installation.

(d) On installations where an MTF exists, the installation commander may delegate the appropriate responsibilities in subparagraphs 4.a.(12)(a) to 4.a.(12)(c) of this enclosure to the MTF commander.

4. Command Responsibilities

(1) Be comprised of a multidisciplinary team, to include, at a minimum, individuals in each of the following areas: (a) Mental health (e.g., a psychiatrist, psychologist,

social worker, psychiatric nurse practitioner, a mental health technician, and/or licensed provider who is trained in acute mental health intervention).

(b) Spiritual support (e.g., a chaplain and chaplain’s assistant).

(c) Family support (e.g., a community readiness consultant).

f. DMHR Teams. DMHR teams shall:

(2) Have a licensed mental health provider serving as the DMHR team leader.

(3) Have the following responsibilities: (a) Coordinate with family assistance centers on

the installation and other agencies as appropriate to arrange DMH services to family and community members impacted by an all- hazards incident. (poses problem for non-local DMHR Team)

f. DMHR Teams. DMHR teams shall:

(b) Establish standard operating procedures (SOP) in accordance with the National Institute of Health Publication [NIMH, 2002] that will include, at a minimum: 1. The composition and role of the team.2. A listing of the available, locally trained resources with contact information. 3. A description of local conditions and any identified high-risk groups.4. A response plan for team activation.5. Plans for conducting DMH needs assessments and surveillance.6. Required initial/periodic training.

f. DMHR Teams. DMHR teams shall:

(c) Establish a plan for maintaining individual DMHR team member psychological health….

(d) Provide DMH services to include prevention, outreach, screening, triage, psychological first aid, education, and specialty referral(s) to individuals and groups who have had or may have had exposure to an all-hazards incident. These services are not medical services, and therefore do not involve medical or mental health record documentation.

f. DMHR Teams. DMHR teams shall:

(e) Train annually as part of the overall installation IEM exercises in accordance with Reference (k). (f) Train at least quarterly as a DMHR team, using evidence-based practices if available, to develop and maintain the competencies necessary to provide DMH services. Training will cover, at a minimum, prevention, outreach, screening, triage, psychological first aid, education, and referral services …command consultation and ethical issues during disasters.

If not medical services, does HIPAA apply?

f. DMHR Teams. DMHR teams shall:

(g) Identify and train primary and alternate DMHR team members for each role to ensure continuous access to DMH services.

(h) Coordinate efforts with the PHEO and integrate efforts of the DMHR team into the overall public health emergency preparedness and response.

f. DMHR Teams. DMHR teams shall:

4 trajectories of Acute Stress Disorder/PTSD Risk factors for PTSD Acute Stress Disorder symptom checklist

Disaster mental health assessment/triage

Time 1 Time 2Acute Stress Disorder PTSD

Subclinical Subclinical

4 trajectories(Bryant, 2013)

High exposure to the traumatic event Population exposure model

Secondary stressors (financial, marital, health probs)

Prior mental health condition/ prior trauma history Lack of positive social support Poor coping skills (low self-efficacy/hope,

avoidance) Demographics : female gender and racial minority

(Norris et al., 2002; or see National Center for PTSD Mental Health Effects Following Disaster: Risk and Resiliency Factors )

Risk factors

Risk/Resiliency FactorsHHS, 2004

HHS, 2004

Changes in diagnostic criteria in DSM-5

Severity of Acute Stress Symptoms—Adult and Child versions National Stressful Events Survey Acute

Stress Disorder Short Scale (NSESSS) http://www.psychiatry.org/practice/dsm/dsm5/

online-assessment-measures

Assessing Acute Stress Disorder

Assess Extent of exposure to the event Other risk/resiliency factors Acute stress symptoms

NO CURRENT ASSESSMENT FORM captures all of this

Knowing who to refer to follow-up care

Assessment conclusion

First four weeks after a traumatic event (NIMH, 2002) Non-traditional model. Similar to Combat and

Operational Stress Control, PIES (Proximity, Immediacy, Expectancy, Simplicity) BICEPS (Brevity, Immediacy, Contact/Centrality,

Expectancy, Proximity, Simplicity). Outreach!

Widespread acceptance of Psychological First Aid Controversy regarding CISD/CISM

Early intervention

Caveat, evidenced-based practice literature is sparse

Difficulties conducting treatment efficacy research in disaster setting,

Psychological First Aid (PFA) is widely accepted evidence-informed early intervention Meant to be utilized by anyone involved (not just

MH) Non-mental health providers may have better

success with those survivors who don’t want to talk to mental health

Can be done very informally Meant for survivors AND fellow disaster responders Mental health providers expertise is providing the

more in-depth follow-up care if needed

Early intervention

Here are some… BUMED (COS First Aid) SAMHSA National Center for PTSD National Child Traumatic

Stress Network Center for Study of

Traumatic Stress, USUHS Medical Reserve Corps NY State Office of MH Florida Center for Public

Health Preparedness American Red Cross Australian Red Cross

International Federation of Red Cross/Crescent

World Health Organization

National Fallen Firefighters Association

US Department of Homeland Security

Schultz & Forbes, 2013

26 published PFA manuals/field guides published by various organizations

Hobfoll et. al., (2007). 5 essential elements of immediate and mid-term mass trauma intervention.

Try to instill1. Calmness2. Safety3. Connectedness4. Self and community efficacy5. Hope

Psychological First Aid

1. Contact and engagement2. Safety and comfort3. Stabilization4. Information gathering (needs/current

concerns)5. Practical assistance6. Connection with social supports7. Information on coping8. Linkage with collaborative services

PFA: 8 core actions

Online PFA training video available at National Child Traumatic Stress Network6 CE/CMEs! http://learn.nctsn.org/enrol/index.php?id=38

PFA Field Operations Guide via NCTSN/NC-PTSDhttp://www.nctsnet.org/nctsn_assets/pdfs/pfa/2/PsyFirstAid.pdf

Great PFA training

PFA Mobile smartphone app

http://www.samhsa.gov/dtac/dtac-resources Multiple “tip sheet” topics in various

languages Have master copies pre-printed in a binder,

just need to print them up as needed Have readily available where survivors and

first-responders are congregating

PFA handouts from SAMHSA

Research shows can be effective if done right…

Extensive training and implementation process

“One-off debriefings” (CISD done minus the larger CISM program) have the potential to re-traumatize some.

NIMH (2002) consensus group indicates to stay away from “debriefing”

CISD/CISM

Outreach on affected populations (Naturale, 2006) Face-to-face (walking around, planning

visits/talks) May require information from the Incident

Command Within the MTF and outside the MTF Coordinate with other resources to avoid

over/underlap Using social media, print, TV/radio

Early intervention

Outreach is psycho-educational in nature. Follow PFA principals Provide awareness of acute stress reactions normalize reactions provide tips on positive vs. negative coping

strategies when/how to self or buddy refer.

Early intervention

USUHS National Center for Disaster Medicine and Public Health/ Center for the Study of Traumatic Stress “This curriculum recommendations

document provides a useful strategy to help educators, program directors, and curriculum developers form curricula for educating health professionals.”

https://ncdmph.usuhs.edu/Documents/BehavioralHealthRecommendations-201401.pdf

Curriculum to develop competence

SAMHSA Disaster Technical Assistance Center (DTAC) http://www.samhsa.gov/dtac Monthly and quarterly e-bulletins and

newsletters, webinars/podcasts, tip sheets Developing Cultural Competence in Disaster

Mental Health Program. http://store.samhsa.gov/shin/content//SMA03-

3828/SMA03-3828.pdf

Curriculum to develop competence

SAMHSA Disaster Behavioral Health Interventions Inventory (May, 2015) http://www.samhsa.gov/sites/default/files/dtac

/supplemental-research-bulletin-may-2015-disaster-behavioral-health-interventions.pdf

SAMHSA Disaster Behavioral Health Preparedness and Response Resources (catalog of many manuals, tipsheets, etc) http://store.samhsa.gov/shin/content//DTAC11-CATALOG/DTA

C11-CATALOG.pdf

HHS (2004). Mental Health response to mass violence and terrorism. A training manual. https://store.samhsa.gov/shin/content/SMA04-3959/SMA04-3959.pdf

Curriculum to develop competence

Bryant, R. (2013). An update of acute stress disorder. PTSD Research Quarterly, 24(1). Brymer M, Jacobs A, Layne C, Pynoos R, Ruzek J, Steinberg A, Vernberg E, Watson, P. (2006). Psychological First Aid: Field Operations Guide. 2nd Edition. National Child Traumatic Stress Network and National Center for PTSD Galea, S., Nandi, A., & Vlahov, D. (2005). The epidemiology of Post-Traumatic Stress Disorder after disasters. Epidemiological Reviews, 27, (1), 78-91. doi: 10.1093/epirev/mxi003Hobfoll, et. al. (2007). 5 essential elements of immediate and mid-term mass trauma intervention: empirical evidence. Psychiatry, 70(4), 316-369.Naturale, A. (2007). Outreach strategies. An experiential description of the outreach methodologies used in the September 11, 2001, disaster response in New York. In Ritchie, Watson, and Friedman’s (Eds) Interventions Following Mass Violence and Disasters. Strategies for Mental Health Practice. Guilford Press. NY.National Center for PTSD Mental Health Effects following Disaster, Risk and Resiliency Factors retrieved from http://www.ptsd.va.gov/professional/pages/effects-disasters-mental-health.asp

References

National Institute of Mental Health (2002). Mental health and mass violence: Evidenced-based early psychological intervention for victims/survivors of mass violence. A workshop to reach consensus on best practice. NIH Publication No. 02-5138, Washington, D.C.: U.S. Government Printing Office.Norris et. al. (2002). 60,000 disaster victims speak: Part I. An empirical

review of the empirical literature. Psychiatry, 65(3), 207-239.Shultz, J. M. & Forbes, D. (2013) Psychological first aid: Rapid proliferation and the search for evidence. Disaster Health, 1(2), P1-10.Wang, W. (2005) The hospital in its community. In Danieli and Dingman’s (Eds.) On the Ground After September 11. Mental Health Responses and Practical Knowledge Gained. Haworth Press, NY.U.S. Department of Health and Human Services (2004). Mental Health Response to Mass Violence and Terrorism: A Training Manual. DHHS Pub. No. SMA 3959. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration

References