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Training primary care workers in disaster mental health


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Training primary care workers in disaster mental health the experience in Ecuador, April 6-11, 1987 : final report
Series Title:
Quick response research report ;
Physical Description:
1 electronic resource (38 p.) : ;
Lima, Bruno R
University of Colorado, Boulder -- Natural Hazards Research and Applications Information Center
Natural Hazards Research and Applications Information Center, University of Colorado
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Boulder, Colo
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Subjects / Keywords:
Disaster victims -- Mental health -- Ecuador   ( lcsh )
Earthquakes -- Psychological aspects -- Ecuador   ( lcsh )
Mental health personnel -- Training of   ( lcsh )
Disaster victims -- Mental health services   ( lcsh )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
bibliography   ( marcgt )
non-fiction   ( marcgt )


Includes bibliographical references (p. 19-27) and index.
Statement of Responsibility:
by Bruno R. Lima.
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Description based on print version recor.d

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aleph - 002021407
oclc - 428093309
usfldc doi - F57-00068
usfldc handle - f57.68
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Natural Hazards Research and Applications Information Center Campus Box 482 University of Colorado Boulder, Colorado 80309 .. 0482 TRAINING PRIMARY CARE WORKERS IN DISASTER MENTAL HEALTH The Experience in Ecuador Bruno R. Lima 1988 Quick Response Research Report #28 Ol rei /-louse Cop .. ':be;; rw t -tCL'tom L/brar Institute of Behavioral Science #6 (303) 492.6818


Training Primary Care Workers in Disaster Mental Health The Experience in Ecuador April 6-11, 1987 Final Report by Bruno R. Lima, MD, MPH Associate Professor Department of Psychiatry School of Medicine Department of Mental Hygiene School Hygiene and Public Health Johns Hopkins University Submitted to the Natural Hazards Research and Information Applications Center, University of Colorado, Boulder, Colorado, September, 1988


Primary Mental Health Care in Disasters Page 2 The Co-Investigators of this project in Ecuador, Colombia and the United States are: 1. Ecuador: Hernan Chavez, M.D. and Nelson Samaniego, M.D. Department of Psychiatry, School of Medicine, Central University of Ecuador, and National Division of Mental Health, Ministry of Public Health, Ecuador. 2. Colombia: Hernan Santacruz, M.D. and Julio Lozano, M.D. Department of Psychiatry, School of Medicine, Universidad Javeriana, Bogota, Colombia. 3. United States: Shaila Pai, Ph.D, Department of Psychiatry, School of Medicine, Silvia Pompei, M.D., M.P.H., Department of Mental Hygiene, School of Hygiene and Public Health, Johns Hopkins University. Address for correspondence: Dr. B. Lima 188 Meyer Bldg. JohIlS Hopkins Hospital 600 North Wolfe Street Baltimore, Maryland 21205 Tet 301-955-2236


Primary Mental Health Care in Disasters Page 3 I. INTRODUCTION The proposed research is the first effort of a long-range project to develop the role of the primary care worker (peW) in providing. mental health care to disaster victims. Its specific aims are: (D to identify the prevalence of psychiatric disorders among victims of different disasters in tent camps and in primary care clinics; (2.) to ascertain the pews' skills in detecting patients with emotional disorders; (1) to evaluate the efficacy of a focused training course on the pews' ability to detect victims with emotional problems; and to probe into the long-term consequences of disasters and alternative management strategies. Associated aims relate to disaster psychopathology and include: CD comparing emotional symptoms of victims of disasters with different magnitudes; and (2.) probing into the relative contributions of individual vulnerabilities, social situation and stressors. II. BACKGROUND AND SIGNIFICANCE Disasters have become increasingly important events to mental health professionals, as the full psychological impact of trauma in the short-and long-term range has been recognized (I -5). The mental health effects of various types of disasters have been studied, including floods (6-12), tornadoes (13-15), fires or explosions 1620), cyclones (21-24), volcanoes (252 7), earthquakes (2833), and various kinds of accidents (34-37), including nuclear accidents (38,39). Various efforts have been developed to deliver mental heath services to disaster victims, but they have focused on the role of the specialized mental health sector in the immediate post-impact phase (40-42). At the same time, primary care was accepted as the main strategy for attaining WHO's goal of "health for all by the year 2000" (43) reflecting a growing awareness of its role in extending services to the population (44,45). Various studies have shown a high prevalence of emotional disorders among primary care attenders (46-53), leading to efforts for integrating health and mental health (54,55), and promoting appropriate mental health skills, attitudes and knowledge in the pew (56). The delivery of mental health care to disaster victims, particularly in the medium and long-term range, also requires the mental health/general health integration, but the pew has not been involved in this process (57) ..


Primary Mental Health Care in Disasters Page 4 As a result, these two lines of research and service delivery have not been combined. This is particularly surprising for the following reasons: (i) Disasters affect more severely individuals in the lower socio-economic strata (58) who usually have the highest rates of psychiatric morbidity but least access to health and mental health resources, and to whom primary care has been recognized as the most appropriate strategy (61); (ii) Disaster victims do not see themselves as psychiatric patients (4), but as individuals under stress, more likely to utilize the general health clinics (62) than mental health services (63); (iii) It has been documented that PCWs can be trained to deliver effective mental health care in routine clinical settings (56); and (iv) Mental health interventions in the medium and .long-term must conform to the policies of the Ministries of Health for routine health care, which follow WHO's primary health care strategy. Recent disasters in Latin America offered an opportunity to bridge this gap. We have studied the mental health consequences of two major disasters with the goal of developing new knowledge and improving service delivery. This experience will be applicable to those regions of developed countries where for various reasons such as scarcity of specialized mental health resources (64) or cultural stigmatization of psychiatric treatment (65) primary care may be the most appropriate strategy for delivering mental heath care. It relates closely to the development and implementation of culturally-appropriate mental health services to the Hispanic population in the U.S., encouraging the adoption of policies to promote the role of the PCW in the delivery of mental health care to victims in Latin American and in the developed world as well. The high concentration of socio-.. economically disadvantaged Hispanic population in disaster-prone areas (eg. California, Southwestern states and South Florida) and their explosive growth further highlight the applicability of this research to the U.S. (66,67). The project will also shed light on issues of disaster psychopathology and stress responses in general (68,69). Different methodologies utilized in the various research studies are considered partially responsible for the conflicting findings on disaster psychopathology (70). Our study addresses this issue, as the existing data were collected in a standardized manner on 450 subjects


Primary Mental Health Care in Disasters Page 5 utilizing the same research instruments and methodology, under the direction of the PI, in the first year after the disasters. To our knowledge, no other data set on Hispanic victims of disasters exist with these characteristics. This standardized information will be utilized to identify similarities in emotional responses to different disasters, which will have tremendous implications for training 'the PCW in disaster mental health. III. PRELIMINARY STUDIES The PI has had a long-standing interest in primary mental health care (73-77). As a result of this interest, he was invited by the Pan American Health Organization to provide consultation to the Colombia Division of Mental Health for developing a national Primary Mental Health Care Plan (7S). The Plan was to be completed in November 19S5 and subsequently pilot-tested in the town of Armero (30,000 population). When the town was destroyed by a volcanic eruption on November 13, 19S5, with over 22,000 causalities (79), the PI's consultation }Vas postponed. However, the special characteristics of the disaster seemed to provide a unique opportunity for studying primary mental care in disasters (SO): most survivors were socio-economically deprived individuals, the target population for primary care; and the regional psychiatric hospital was destroyed, shifting to the general/primary health care sectors the responsibility for delivering mental health care. Taking advantage of this "naturalistic experiment," the PI submitted that a special primary mental health consultation should be provided, which was carried out immediately (Sl). It led to the development of the Armero and Ecuador projects, which represent the initial steps towards developing primary mental health care in disaster. Figure I gives an overview of the project whose rationale and origins have been reported in detail (SO). The Armero data address prevalence and detection. The Ecuador project replicates these goals and probes into issues of training and its evaluation. In this report, we will describe the methodology of the project as a whole, focusing on the frequency of emotional disorders of adult patients attending primary cost clinics in Ecuador, which will be compared to our earlier research in Armero. The analyses of the primary are worker's skills in detecting patients with


Primary Mental Health Care in Disasters Page 6 emotional disorders will be done later. Funds from the Quick Response Grant do not support data analysis, and the analytical work done so far has been funded by the Department of Psychiatry of Johns Hopkins. A grant proposal has been submitted to the National Institute of Mental Health to complete the analyses, but its review is now pending. "IV. EXPERIMENTAL DESIGN AND METHODS This section contains a detailed description of (1) the variables, (2) the research instruments, and (3) the design of the three studies (Armero tents, Armero Clinics, and Ecuador). The existing data on the Colombian and Ecuadorian disasters provide information on the extent of psychiatric problems among victims, and probe into the ability of the PCW in detecting victims with emotional disorders. We plan to analyze this data will on three levels: descriptive (prevalence of emotional distress and psychiatric disorders among victims), analytical (identification of personal and environment risk factors that may modify response to disaster) and experimental (training course of PCws on disaster mental health). However, only partial analyses will be reported here. (Section V). 1. Variables: The variables relate to, the victims and to the PCWs. For the victims, variables can be grouped into three categories: independent, mediating, and outcome variables. The independing and mediating variables studied related to the overall goals of the project, both in its theoretical and service delivery aspects. The independent variables (e.g., personal disposition) relate to those features preceding the disaster: victims sociodemographic characteristics, developmental history, personality traits, previous significant losses, history of medical and psychiatric disorders and treatments. The mediating variables (Le. stressors and social situation) related to the disaster experience level of exposure and severity of losses) and to post-disaster conditions (e.g. housing in shelter/camp, level of social support, and life events/stressors). The outcome variables relate to the psychosocial consequences of the disaster: levels of emotional distress, psychiatric diagnosis, and utilization of


Primary Mental Health Care in Disasters Page 7 general health and mental health services. By ascertaining the relative contribution of stressor, personal disposition and social situation to outcome, we will gain a greater understanding of the "pathophysiology" of disasters, with significant implications for developing models of stress-related psychopathology and for implementing management interventions (82). For the PCW, the independent variables include age, sex, education, years of professional experience, baseline data on their level of knowledge in a disaster mental health, and their skills in correctly detecting with emotional disorders. The dependent variables relate to the effects of the training course on the PCWs' knowledge of disaster mental health, and on their detection skills. 2. Instruments: The instruments used are: (a) the Self-Reporting Questionnaire, (b) the Mini-Mental State Examination, (c) the Clinical Interview Schedule, (d) the DSM-III checklist, (e) the Health Staff Review, and (f) Questionnaires on disaster mental health. Some of the instruments already existed in Spanish, such as the Self Reporting Questionnaire and the Mini-Mental State Examination. A few content modifications in the Mini-Mental State Examination had to be made to adjust it to the local culture. The Clinical Interview Schedule was the one used routinely by the local practitioners, and the Questionnaire developed by the Ecuadorian research team exist only in Spanish. A Spanish version of the DSM-III checklist was prepared by the research team and presented to research clinicians who agreed on the semantic, clinical and cultural appropriateness of the translation. a. The Self-Reporting Questionnaire (SRQ) is a simple and reliable instrument widely used in developing countries (83-85). It indicates that an individual with a positive score is likely to be a "case", the final criteria for caseness resting on a psychiatric examination. b. The Mini-Mental Status Examination (MMSE) is a simple and reliable method for detecting cognitive disorders (86-89), which has also been used with Hispanic Populations (90,91). Given the funding limitations, the MMSE was not applied to the clinic subjects.


Primary Mental Health Care in Disasters Page 8 c. Clinical Interview Schedule was developed taking into consideration the training of the clinicians, the specific disaster circumstances, and the need to produce generalizable results. It gathered information on the victims' socio-demographic background, family and personal history, pre-morbid personality, previous psychiatric disorder, past and current medical disorders, health and mental health care received, disaster experience, current emotional problems, and mental status examination, and clinical diagnosis. d. The Symptom Checklist (92) was appended to the interview schedule to generate standardized DSM-III diagnoses. The clinicians were asked to check those symptoms they had identified, which were subsequently reviewed by an independent rater familiar with DSM-III criteria. e. The Health Staff Review (HSR) was completed by the PCW to assess their ability to detect emotional problems. Because of its simplicity and brevity, it has been readily accepted PCWs elsewhere (56). It asks whether the patient suffers from: (i) a physical disorder only; (ii) an emotional disorder only; (iii) both a physical and an emotional disorder; and (iv) neither. If the PCW indicates the patient is suffering from an emotional disorder only or in association with a physical disorder, it is considered that the PCW has detected an emotional problem. This detection by the PCW is compared with the results of the SRQ administered by the research team (probable case) and/or with clinical examination conducted by the research psychiatrist (definite case). Therefore, the ability of the PCW in identifying cases with emotional disorders is not based on his/her self-report; rather, it results from comparing the PCW's detected case with the cases identified by the SRQ and/or with the psychiatrist's exam. f. A Questionnaire was developed to assess the PCWs' knowledge on disaster mental health and given to the PCWs before the training, after its completion, and 2 months later.


Primary Mental Health Care in Disasters Page 9 3. Study Design: Figures 2-4 outline the research design of each study. In this section we will summarize the Armero project and present in greater detail the Ecuador findings. a. The Armero Project This project was supported by grants of the Natural Hazards Research and Applications Information Center of the University of Colorado in Boulder and the Johns Hopkins University Institutional Research Grant Projects Committee. Their expedite review process permitted all the data collection to be completed within one year after the disaster. No funds were available for data analysis, however, in either grant. The Armero design is outlined in Figures 2 and 3. The specific aims of the Armero project were to ascertain the prevalence of emotional disorders in tent camps and primary case clinics eight and eleven months after the disaster, respectively. The sample in tents (Fig. 2) consisted of 200 adults in three camps and a convenience sample a fourth site. No significant differences exis-t between these samples. For the Clinics (Fig. 3), we screened 100 consecutive adult patients. We attempted at interviewing all subjects who scored positively. Due to pressures for service delivery in a post-disaster situation, we interviewed only a third of those who scored negatively. The PCWs in the clinics documented the detection of patients with emotional problems by completing the HSR. Detailed descriptions of this research methodology have been reported (93). Only preliminary analyses of the data from the Armero camps have been conducted with limited general funds from the Johns Hopkins Department of Psychiatry. The results indicate a high prevalence of emotional distress among victims in tent camps (94) and among patients in primary care clinics, with a significant under-recognition of emotionally distressed patients by the PCW (95). The Armero project and its findings were reported in a summary paper (96) which received the ACTA award in Buenos Aires, Argentina.


Primary Mental Health Care in Disasters Page 10 b. The Ecuador Proiect: The Ecuador project was supported by funds from the Natural Hazards Research and Applications Information Center of the University of Colorado in Boulder. It studied victims of the major earthquakes that struck the northern provinces if the country in March 1987, and replicated the Armero project in ascertaining the prevalence of emotional disorders and their detection by the PCW, and in utilizing the same instruments and research design for generating comparable data. In addition, it probed into the issues of training by developing and evaluating a course for the PCW. The study design is outlined in Figure 4. As the Ecuador project had as its main goal ascertaining the effect of a training course on the PCWs in detecting emotional disorders among disaster victims, we were concerned about the issue of a control group. The general practitioners available for the training worked in a small geographic area and had expressed extreme interest in obtaining the necessary knowledge. We felt that having an untrained control group would be neither appropriate nor feasible: it would be difficult to justify withholding training for the duration of the study; and the new information on disaster mental health would probably be shared by all doctors, contaminating the control group. Therefore, we chose a pre/post design. All general practitioners of the region (N-35) received identical training, but only 10 participated in the study. We utilized the same methodology previously described in the study of patients in the Armero clinics for ascertaining the prevalence of emotional distress and the detection by the PCW. The screening was conducted before and after the training. A total of 150 patients were studied. Before the training, a systematic sample of 50 adult patients coming to 10 selected primary care clinics in .the disaster area were screened with the SRQ. The PCWs were given the HSR to be completed for each patient recruited into the study. A 2-day training course was then given to the PCWs utilizing as the basic document the "Manual on Disaster Mental Health for the PCW" (97). The Manual addresses the psychiatric' phenomenology of disaster victims interviewing techniques, psychiatric symptoms and frequent psychiatric disorders. For each of these disorders, diagnostic guidelines are given and simple management techniques are provided,


Primary Mental Health Care in Disasters Page II with specified thresholds for referral to the specialized mental health sector. A special section on problems seen in children and adolescents is included. After the training, 100 consecutive patients not enrolled in the pre-training phase were screened using the SRQ, and the identification skills of the PCWs were evaluated by comparing their response to the HSR with the result of the SRQ. No budget existed for psychiatric interviews. Utilizing their own limited resources, however, the Ecuadorian research team decided to interview those patients who scored positively on the SRQ (N=57). The same instruments used in the Armero project were utilized. Forty-one patients were interviewed by the psychiatrist: a clinical diagnosis was entered and a DSM-III symptom-checklist was completed. The entire s.tudo/ was completed in 2 months. v. RESULTS For the Armero phase of the project, our findings have been reported (94, 96). In this section, we will report the Ecuador findings. Table I shows the socio-demographic characteristics of our study sample (N=150). Three fourths of the sample were female, and eighty percent were under age 44. Two thirds were either married or had a common-law relationship, and had education up to 6 years of school. All subjects were of mixed racial composition. The prevalence of emotional distress as defined by the SRQ was 40%. The mean score for the neurotic subscale of the SRQ for those with a positive result (9.73 3.91) was two and a half the mean score for those subjects with a negative score (3.76 1.93), a difference that is very significant (P <.0001). Individual symptoms of the SRQ were investigated to see whether they could predict emotional distress. Table 2 shows that all symptoms of the SRQ predicted emotional distress with a high level of statistical significance. The most frequent symptoms were "being easily frightened" (Question 4, n-I05), "feeling nervous, tense or worried" (Question 6, n-IOI) and "feeling easily tired" or "sleeping badly" (Questions 3 and 20, n=65). These symptoms, however, were among the weakest


Primary Mental Health Care in Disasters Page 12 predictors of emotional distress: only about half of the patients with these symptoms were identified by the instrument as emotionally distressed. The strongest predictors of emotional distress were among the most infrequent symptoms: "having difficulty enjoying daily activities" (Question 11, n=28), "feeling like a worthless person" (Question 16, n ... 21), and "feeling unable to playa useful part in life" (Question 14, n .. 22). When a patient presented these infrequent symptoms, however, about eight out of ten times he/she would be identified by the instrument as being emotionally distressed. Table 3 lists various variables associated with emotional distress. Of the socio-demographic variables studied only marital status was predictive of distress: patients who were either single, separated or widowed were significantly more liket"y to be emotionally distressed than if they were married. The self -perception of poor physical or emotional status was also significantly associated with emotional distress. When the physical symptoms presented by the patients were studied, only the ill-defined conditions were significantly associated with a positive SRQ score. These conditions included poorly defined aches and pains, fatigue, and non-specific gastrointestinal complaints. No association was noted between SRQ scores and age, sex, education, occupation, loss or change of job, reason for clinic visit, various aspects of the disasters injuries, life events between disaster and screening, level of social support, and having plans for the future. VI. DISCUSSION The findings described in this report indicate a high frequency of emotional distress among patients attending primary care clinics in the area affected by the earthquakes in Ecuador. The prevalence of emotional disorders among patients attending primary care clinics in Ecuador was almost three times higher than the prevalence seen among primary care attenders in routine clinical situations utilizing the same instrument (28). We did not obtain data on a control group. The entire population over a very extensive area had been affected by the earthquakes. A control group would have to be recruited from elsewhere, which was impractical, and in a post-disaster situation, actually impossible. However, the large difference in the prevalence rates in a post-disaster situation and in routine clinical settings supports the causal of the association between the disaster and the


Primary Mental Health Care in Disasters Page 13 identified level of emotional problems. Certain variables relate to the presence of emotional distress among victims. Victims who are who are single, separated or widowed are more likely to be emotionally distressed. A reported good physical health is strongly associated with stable emotional state. It is of course difficult to establish the direction of this association: physical problems may have led to emotional distress, or emotional distress may have been perceived and translated as physical problems. The end result, however, is that the presence of actual physical problems or the perception of poor physical health seem to be associated with emotional distress. This is particularly so when patients complain of ill-defined physical symptoms. These patients were significantly more likely to be emotionally distressed than patients who presented complaints that had a close relationship with well-defined physical disorders. This observation has been made in various routine situations (98); our Armero data on victims in tent camps showed the same pattern (93). The findings are also consistent with the earlier data produced by the Armero investigation. In interpreting the Ecuador data, it is important to note the various similarities with the patients surveyed in the Armero clinics. Compared to the Armero sample, the Ecuador subjects include a greater proportion of women; no other sociodemographic variables are significantly different. When the prevalence of emotional distress among the Ecuador victims is compared with the rates for the victims of Armero, an important relationship is noted. In Armero, the highest prevalence (55%) was found among victims of tent camps, who were directly and severely affected by the disaster, having been rendered homeless (94); an intermediate rate (45%) was found in a sample of patients attending primary care clinics of the disaster area. Half of this sample was comprised of subjects from the neighboring towns who had not been directly affected by the mudslide, but whose lives had been significantly changed by the tragedy and by the continuing threat of new eruptions (95). The lowest rate (40%) was found in Ecuador, where there were very few casualties and the property damage was significantly less severe. These rates suggest that the proportion of victims with emotional distress relates directly to the magnitude of the disaster. The


Primary Mental Health Care in Disasters Page 14 mean scores for the neurotic subscale score, however, show that the severity of symptoms for these three groups of subjects with a positive SRQ score was similar: in Armero, for the victims in camps it was of 9.78 4.36, and for the patients in the clinics it was of 8.87 3.8; in Ecuador, it was of 9.73 3.77. For the victims with a negative SRQ score, the mean scores for the neurotic subscales were 3.39 2.14, 4.16 2.04, and 3.78 1.93, respectively. These results indicate that once a victim becomes distressed, the level of symptomatology is similar irrespective of the magnitude of the disaster; but those who do not become emotionally distressed present a remarkable paucity of symptoms. This suggests a dose-response model for the prevalence of emotional distress, and a threshold phenomenon for symptom-severity: the proportion of emotionally distressed victims is higher in disasters of greater magnitude, but the number of symptoms among the distressed and the relative absence of emotional problems among the non-distressed are similar irrespective of the disaster. When the frequency of symptoms and their capacity to predict emotional distress as defined by the SRQ are analyzed among the Ecuador subjects, an inverse relationship emerges: commonly reported symptoms are weak predictors, whereas less frequently reported symptoms are strong predictors. A similar pattern was noted among victims of the Armero disaster. In the Ecuador and Armero samples, the two most common symptoms were "feeling nervous, tense or worried," and "being easily frightened." "Feeling easily tired" was the third most common symptom in Ecuador and the fourth in the Colombian sample. These symptoms have the lowest rank order in predicting emotional distress. When the strongest predictors of emotional stress are examined, we see that "feeling unable to playa useful part in life" and "feeling like a worthless person" are ranked amongst the three strongest predictors in both sites, although their rank orders in frequency are the lowest. It is interesting to note that the most frequent symptoms detected by the SRQ among the victims both in Armero and Ecuador refer mostly to anxiety, whereas the strongest predictors refer mostly to depression and social dysfunction. The clinical examination of a subsample of the Armero victims in tent camps showed that the most frequent psychiatric diagnoses among those with a


Primary Mental Health Care in Disasters Page 15 positive SRQ score were post-traumatic stress disorder and major depression (93) which suggests that anxiety and depression may indeed be the most frequent and relevant symptoms among victims of various kinds of disasters. Finally, the symptom-profiles of the neurotic subscale for these sets of data indicate a remarkable similarity among the subjects with a positive SRQ score (Figure 5): the curves show a remarkable overlapping scores for victims in tent camps in Armero, and for patients in primary care clinics in Armero and Ecuador. These data further emphasize the similarity in emotional responsiveness of victims to different disasters. The utilization of the PCW in delivering mental health care to disaster victims will benefit from these findings which represent empirical guidelines for designing a focussed mental health training. These findings, however surprising, are very promising. Disasters with different impacts could elicit different patterns of emotional response. The consistency of symptoms in Armero and Ecuador seems to indicate that human beings under severe stress, once a given threshold is reached, may present relatively similar emotional responses. This implies that in disasters of lessened magnitude, we may find fewer victims with emotional distress, but the distressed individuals will be as symptomatic as victims of a major catastrophe, and will require the same level of care. The PCW needs to be properly prepared to identify and manage these emotional problems. Under-recognition of emotional distress by the PCW however, has been widely documented in various health settings, both in developed (99,100) and in developing countries (52). Similar observations were made by us among disaster victims attending the primary care clinics in Armero, where the pew failed to diagnose 75% of those patients who had been identified as emotionally distressed by the SRQ (95). Although the training of the pew in basic mental health actions has been successfully implemented in various routine situations (56), additional knowledge on disaster mental health needs to be gained for the adequate training of the pew. Given the magnitude of the problem, the scarcity of resources and the pressured time frame, the training of the pew in disaster mental health must be carefully designed to meet the victims' needs. It cannot be too narrow, as the


Primary Mental Health Care in Disasters Page 16 PCW will not be able to detect and manage certain conditions not emphasized in routine training, as the post-traumatic stress disorder. Nor can it be too broad, as scarce resources would be wasted in triuning the PCW for the management of conditions unlikely to be present among disaster victims, such as acute psychotic states. These findings also underscore the need for the PCW to be able to identify and manage relatively severe levels of emotional distress. in victims of disasters, regardless of their magnitude. The frequency of distressed victims may vary according to the impact of the disaster, but once a victim becomes emotionally distressed, the types and severity of symptoms can be expected to b.e the same . This training program should also draw the PCWs' attention to those factors likely to be associated with significant emotional distress among disaster victims, such as certain personal characteristics (e.g., not being married), report of poor physical health or of certain symptoms (e.g., nonspecific physical complaints), or specific emotional symptoms (e.g., having difficulties in enjoying daily activities). VII. CONCLUSIONS This study produced important data for understanding the relationship between disaster and psychological problems. It showed that the earthquakes in Ecuador produced a high level of emotional distress among patients in primary care clinics. It also permitted the identification of symptoms and variables which seem to predict emotional problems. This report also takes advantage of the fact that the same research strategy and instruments were utilized by the authors in Armero and Ecuador, which permits the comparison of these data sets. Its major comparative findings are: (i) the frequency of emotional distress among disaster victims is proportional to the magnitude of the catastrophic events; (ii) the level and pattern of symptoms among the distressed are similar for victims of different disasters; and (iii) the most common and the strongest predictors of emotional distress are essentially the same for aU the subjects studied.


Primary Mental Health Care in Disasters Page 17 The initial results from Armero had provided guidelines for producing a Manual (97) which has been piloted in the mental health training of rural doctors and nurses local to the disaster areas (101). The findings from this present study in Ecuador replicate many of the original observations made with the Armero victims, emphasize the similarity of emotional problems among victims on disasters with different magnitudes, and support our efforts to develop and implement a manual of disaster mental health for the training of the PCW with applicability in Latin America.


Primary Mental Health Care in Disasters Page 18 ACKNOWLEDGEMENTS: We indebted to the students of the School of Medicine, Central University of who collected the data utilized in this report with great skill and enthusiasm: Ivan Balarezo, Manuel Balzeon, Arturo Bravo, Marco Cruz, Paul Davila, Galo Enriquez, Mauricio Guerrero, Ramiro Rueda, Edgar Samaniego and Luis Viera. Supported by the Natural Hazards Research and Applications Information Center, University of Colorado, the Diyision of Mental Health of the Ecuadorian Ministry of Health, and the Department of Psychiatry of the Johns Hopkins University School of Medicine.


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Primary Mental Health Care in Disasters Page 23 53. Schurman RA, Kramer PO, Mitchell JB. The hidden mental health network. Arch Gen Psychiatry, 42:89-94, 1985. 54. Pincus HA. Linking general health and mental systems of care. Am J Psychiatry, ill:315-320, 1980. 55. Goldman HH. Integrating health and mental health services. Am J Psychiatry, lli:616-620, 1982. 56. Srinivasa Murthy R, Wig NN. The WHO collaborative study on strategies for extending mental health care. Am J Psychiatry, 140:1486-1490, 1983. 57. Lima BR. Primary mental health care for disaster victims in developing countries. Disasters, lQ.:203-204, 1986. 58. Seaman J (ed). Epidemiology of Natural Disasters. Basel, Karger, 1984. 59. Hollingshead AB, Redlich FC. Social Class and Mental Illness. New York, John Wile and Sons, Inc, 1958. 60. Shapiro S, Skinner E, Kesler L. Vonkorff M, German PS, Tischler GL, Leaf PJ, Benham L, CottIer L, Regier DA. Utilization of health and mental health services. Arch of Gen Psychiatry, !l:971-978, 1989. 61. Pan American health Organization. Health For All by the Year 2000. Washington, D.C., PAHO, 1980. 62. Lindy JP Grace MC, Green B. Survivors: Outreach to a reluctant population. Am J Orthopsychiatry, ll:468-478, 1981. 63. McFarlane AC. Post Traumatic morbidity of a disaster. J Nerv ment Dis, 174:4-14, 1986. 64. Burns BJ, Burke JD, Ozarin LD. Linking health and mental health services in rural areas. lot J Ment Health, .l2.:130-143, 1983.


Primary Mental Health Care in Disasters Page 24 65. France RD, Weddington WW Jr, Houpt JL. Referral of patients from primary care physicians to a community mental health center .. J Nerv Ment Dis, .l.22:594-598, 1978. 66. U.S. Bureau of the Census.Projection of the Hispanic Population 1983 to 2080. Pub No. 995, Washington, D.C., US GPO, 1986. 67. Tierney K, Banden B. Crisis Intervention Programs for Disaster Victims. Washington, D.C., U.S. Government Printing Office, 1979. 68. Dohrenwend BP, Dohrenwend BS. Social environmental factors, stress and psychopathology. Am J Comm Psychol, 2.:128-159, 1979. 69. Dohrenwend BP, Dohrenwend BS, Warheit G, Bartlett GS, Goldsteen K, Martin JL. Stress in the community. Ann NY Acad Sci, 1981. 70. Green BL. Assessing levels of psychological impairment following disaster. J Nerv Ment Dis, 11.!l:544-552, 1982. 71. McFarlane AC. The effects of stressful life events and disasters. A ust N Z J Psychiatry, 12.:409-421, 1985. 72. Dohrenwend BS, Dohrenwend BP. Some issues in research on stressful life events. J Nerv Ment Dis, 73. Lima BR (ed). Manual de Treinamento em Cuidados Primarios de Saude Mental. Porto Alegre, Brazil: Secretaria de Saude e do Meio Ambiente do Rio Grande do SuI, 1981. 74. Busnello E, Lima BR, Bertolote J. Psychiatric and Psychosocial Issues in Vila San Jose do Murialdo Setting in Brazil. In: Jablensky, A. (ed). International Perspectives in the Diagnosis and Classification of Mental Disorders. Alcoholand Drug-Related Problems. Amsterdam, Excerpta Medica, 1985, p. 383-390. 75. Lima BR, Brooks ML. Coordination of services for outpatients under concurrent medical and psychiatric care. Gen Hosp Psychiatry, 1:330-333, 1985.


Primary Mental Health Care in Disasters Page 25 76. Lima BR, Busnello E. The psychosocial components of health problems in primary. Black Psychiatrists Assoc 0, U:2-8, 1986. 77. Lima BR, Pai S. Concurrent medical and psychiatric disorders among schizophrenic and neurotic patients. Comm Ment Health J, ll:30-39, 1987. 78. Colombia, Ministerio de Salud. Plan de Atenci6n Primaria en Salud Mental. Bogota, Colombia, Ministerio de Salud, 1986. 79. Sigurdsson H, Carey S. Volcanic disasters in Latin America and the 13th November 1985 eruption of Nevado del Ruiz Volcano in Colombia. Disasters, lQ:205-217, 1986. 80. Lima BR, Santacruz H, Loranzo J. Luna J. Planning for Health/Mental Health Integration in Emergencies. In: Lystad, M. (ed) Mental Health Response to Mass Emergencies: Theory and Practice. New York, Brunner/Mazel, 1980, p.371-393. 81. Lima BR. Asesoria en salud mental a raiz del desastre de Armero en Colombia. Bol Of Sanit Panamer, lQl:678-683, 1986. 82. Killilea M. Interaction of crisis theory, coping strategies, and social systems. In: Schulberg HC, Killilea M (ed). The Modern Practice of Community Mental Health. San Francisco, Jossey-Bass Pub, 1982, p.163-214. 83. Harding TW, Climent CE, Diop MD, Diop MB, Giel R, Ibrahim HHA, Srinivasa Murthy R, Suleiman MA, Wig NN. The WHO collaborative study on strategies for extending mental heath care. Am J Psychiatry, 140:1474-1480, 1983. 84. Mari JJ, Wiiliams P. A comparison of the validity of two psychiatric screening Questionnaires. Psychol Med, U:651-659, 1985. 85. Sen B, Wilksinson G, Mari JJ. Psychiatric morbidity in primary health care. fu:..1 Psychiatry, ill:33-38, 1987. 86. Folstein MF, Folstein S, McHugh PRo Mini-Mental Status. J Psychiat Res, 11:189198, 1975.


Primary Mental Health Care in Disasters Page 26 87. Knights EB, Folstein MF. Unsuspected emotional and cognitive disturbance in medical patients. Ann Int Med, li:723-724, 1977. 88. Anthony JC, Leresche LA, Niaz U, Vonkorff MR, Folstein MF. Limits of the "Mini Mental State" as a screening test. Psychol Med, 12.:397-408, 1982. 89. Robins LN, Helzer JE, Weissman MM, Orvaschel H, Gruenberg EM, Burke JD, Regier DA. Lifetime prevalence of specific psychiatric disorders in three sites. Arch Gen Psychiatry, 41:949-958, 1984. 90. Escobar 11, Burnam A, Karno M, Forsyhe A, Landsverk J, Golding JM. Use of the Mini-Mental State Examination (MMSE) in a community population of mixed ethnicity. J Nerv Ment Dis, 174:607-614, 1986. 91. Bird HR, Canino G, Stipec MR, Shrout P. Use of the Mini-Mental Status Examination in a Hispanic Sample. Unpublished Manuscript. 92. Helzer JE. DSM-III Criteria Checklist. Department of Psychiatry, Washington University School of Medicine, St. Louis, 1984. 93. Lima BR, Pai S, Santacruz H, Lozano J, Luna J. Primary mental health care in disasters: Arniero. Colombia. The prevalence of psychiatric among victims in tent camps. Working Paper Series No. 62. Boulder, Colorado: Institute of Behavioral Science, University of Colorado, 1988. 94. Lima BR, Pai S, Santacruz H, Lozzano J, Luna J. Screening for the psychological consequences of a major disaster in a developing country. Acta Psychiat Scand, 1987. 95. Lima BR, Pompei MS, Santacruz T, Lozano J, Pai, S. La deteccion de problemas emocionales por el trabajador de atencion primaria en situaciones de desastre. Experiencia en Armero, Colombia. Salud Mental, in press. 96. Lima BR, Santacruz H, Lozano J, Pai S. La atenci6n primaria en salud mental para victimas de desastres: Armero, Colombia. Acta Psig Psicol Am Lat, 13-32, 1988.


Primary Mental Health Care in Disasters Page 27 97. Lima BR. La atencion primaria en salud mental para victimas de desastres. Manual para la capacitacion del trabajador de atencion primaria. Colombia: Ministerio de Salud, 1987. 98. Hanklin JR, SteinwachsDM, Regier DA. Use of general medical services by persons with mental disorders. Arch Gen Psychiatry, J2:225-231, 1987. 99. Brody DS. Physician recognition of behavioral, psychological, and social aspects of mental care. Arch Intern Med. HQ:1286-1289, 1980. 100. Thompson TL, Stoudemire A, Mitchell WD, Grant RL. Underrecognition of patients' psychosocial distress in a University Hospital medical clinic. Am J Psychiatry, 1983. 101. Lima BR, Lozano J, Santacruz H. Atencion en salud mental para victiinas de desastres. Actividades desarrolladas en Armero, Colombia. Bol Of Sanit Panam 104, 593-598,1988.


TABLE 1 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE VICTIMS OF THE ECUADOR DISASTER (N-150) N ?t! SEX Male 28 18.7 Female 122 81.3 A!a (YEARS) <18 9 6.0 18-44 113 75.3 45-64 14 9.3 65+ 14 9.3 MARITAL ST ATUS Single 33 22.1 Maried/Common Law 102 68.5 Separated 3 2.0 Widowed 11 7.4 EDUCATION (YEARS) None 12 8.4 1-6 83 58.0 7-12 42 29.4 13+ 6 4.2


. ---------_.--........... .. ....... _-.... ---.-. .... .. ... -.... '. . ... TABLE 2 PREVALENCE (%) OF EMOTIONAL DISTRESS DEFINED BY '1'HE SRQ-BY NEUROTIC SYMPTOMS INCLUDED IN THE SRQ AMONG VICTIMS OF '!'HE ECUADOR DISASTER (N=lSO) SYMPTOM PRESENT? YES NO ,'WITH \ WITH EMOTIONAL EMOTIONAL NEUROTIC SYMPTOMS N DISTRESS N DISTRESS P l. DO YOU OFTEN HAVE HEADACHES? 54 69 96 24 <'0001 2. IS YOUR APPETITE POOR? 51 67 98 27 <.0001 3. DO YOU SLEEP BADLY? 65 60 85 25 <. 0001 4. ARE YOU EASILY FRIGHTENED? 105 47 44 25 <'02 5. DO YOUR HANDS SHAKE? 59 56 91 30 <.002 6. DO YOU FEEL NERVOUS, TENSE OR WORRIED? 101 53 48 .15 <'0001 7. IS YOUR DIGESTION POOR? 26 62 124 36 (,02 8. DO YOU HAVE TROUBLE THINKING CLEARLY? 49 70 101 26<'0001 9. DO YOU FEEL UNHAPPY? 37 70 112 30 <'0001 10. DO YOU CRY MORE THAN USUAL? 47 70 103 26 <'0001 11. DO YOU FIND IT DIFFICULT TO ENJOY YOUR DAILY ACTIVITIES? 28 93 121 27 <'0001 12. DO YOU FIND IT DIFFICULT TO MAKE DECISIONS? 46 65 104 29 <'0001 13. IS YOUR DAILY WORK SUFFERING? 25 68 124 34 <.002






________________ : 'hata'-' Cl.1Jl1ca Pr .... l.nce in (!!!!:!i) stadt o..iga: Daacriptiv./Analytical Se. Fi9U" 2 JbIber dir.ctly affecta4 acr--Sz 200 Intard-.5s 102 1r.lU-Ut IPlQa Clinic.l Int.rvi .. DSM-Ill Chacklut 1D health cara tt1D4. (danAftd) POI". cSatect1cn---De.criptiva/Analrtical a.e Figura 1 Prev.lenca 1n health tt1D4. (demand) PCW.' detection POI.' r pon.a to tralniOSl De.cripti .. a/ADalytical/' lxperu-ntal a.e Fi;ura. 4 Vlctw. and non-vJ.ctu.. Victw. and non-.. 1ctw. affecta4 con-Dltia. affecta4 100 SO SRO Clinic.l Int.rvi .. DSM-IIl Checkli.t !tSR 150 41 SRO clinical Intarvi .. DSM-lll CbaCklut RSR Long-t.rm probe into De.criptlv./Analytical See r i;ura 5 tant victlaa. no. in per.anant hou.1D9 150 \50 DO Clinical Intervi .. DSM-lll ChaCklut MMD Eaation.l di.tre.. Eaational di.tre.. !motional di.tre Mc11tiGaal ADaly-. to be Dalla: .) for aecb 1n41 y .tuctr: P.ychi.tric diagno... P.ych1.tric d1aqno.a. Psychiatric diaqno... Psychiatric di.9DO.a. Coqnlt1va Oetection by PCW Po.t-trainiD4 chanq.. 1n 009n1t1... t.patrm.Dt Non. Riqh of a.otional Mo.t frequ.nt diagno.i.: po.ttr.umatic .tr cUaordar tiona K19h of a.otional di.tre Low d.tection of pati.nt. vith aeotlonal dilltne. d.tection of c .... bJ' PCW. re.ult of trainIng Trainin9 of PCW. Rlqh of a.otional di.tre I I I Non. No cSat. collected I R.lation.hip betvaen Frequ.ncy of specific (s..-SRQ and di.qno.1. FLOS: .. in Araaro Cl..1a1ca) IS... .. In Anlero PLUS: Pr.dictor. of apacific plicat. analys vlth Ch&n9 in cSatection tant victilna 1n relation of pati.nt. vith Subclinical conditions to othar ..ational by hlararchy of diaqno.e. i .u.. and gtil1&ation PCW. .econdary to utillz.ation of haalth of .erv1c.. interv.ntion _rvic.. Analyaa detection by the POI. in CCIIIIparuon to SRO Probe into 1 .ua. of expcMVre to 41.a .. tar three years .ft.r di.a.tar Prot.ctive facton R18k factore Slqniflcant lifa-.venta Eff.ct and t.portanc. of helpiD4 rvice. It) CXIAIpUiDg -tltili cSata collecta4 w1th the __ and ai.Her r ... arch cSaa19D foar co.p&ra a.otional .r-Pla.. of victt.. of di ... t.r. ADd to certaiD the relatlve contribution of .badJ._1 of .tra.l!Ore. personal diapoaition and aceial aituatioD to cb rva4 1 pcw. Priaary car. WorkuJ 2 DO Self aaport1", gua.tionoa.1r.J 1 IMR Mini-Mental ltat. 4 HSR. Health ltaff ..


FIGURE 2 EXISTING DATA ARHERO TENT CAMPS Recruited Subjects (N = 200) \ SRQand MMSE 111* administered by research team ============================') SRQ Positive (N = 110) I SRQ Negative (N = 90) I Available for Interview ====> '(N 90) ===========) (N = 87) I I Clinical Interview. Schedule and DSM-III checklist by psychiatrist ) eN = a8) ===========') (N= 34) Cases (N = 62) Non-cases (N = a) cases N = 9) Non-cases (N = 25) ." SRQ ."." MMSE = Self Reporting Questionnaire = Mini-Mental State Examination PRELIMINARY MAIN FINDINGS: High prevalence of of emotional distress Most frequent DSM-III diagnoses: -post-traumatic stress disorder -major depression '. ADDITIONAL ANALYSES '1'0 BE DONE: Relationship between SRQ and diagnosis Predictors of specific diagnoses Phenomenology of subclinical conditions Hierarchy of diagnoses Utilization of health and mental health services '.


FIGURE 3 EXISTING DATA ARMERO PRIMARY CARE CLINICS Recruited Subjects* (N = 100) SRQ** administered HSR*** completed by by r.esearch team =====>. <==== primary care worker independently Clinical Interview SRQ+ (N = 45) HSR+ (N = 12) SRQ (N = 54) tHSR (N = 46) Schedule and ========>(N = 25) =======> (N = 25) DSM-III Symptom Check list by Psychiatrist Cases (N = ?) Non-cases (N = ?) one patient was excluded Cases (N = ?) Non-cases (N = ?) ** SRQ = Self Reporting Questionnaire *** HSR = Health Staff Review PRELIMINARY MAIN FINDINGS.: High prevalence of of emotional distress Low detection of patients with emotional distress by primary care worker ADDITIONAL ANALYSES'l'O BE DONE: Frequency of specific DSM-III diagnoses Relationship between SRQ and DSM III diagnoses Predictors of specific diagnoses by SRQ results Phenomenology of subclinical conditions Hierarchy of diagnoses utilization of health and mental health services Detection of patients with emotional problems by primary care worker in comparison to psychiatric diagnoses Probe into issues of disaster exposure as sample includes subjects who have been affected by the disaster in different ways


FIGURE 4 EXISTING DATA ECUADOR PRE-TRAINING Recruited Subjects (N = 50) SRQ* administered by research team SRQ+ (N = 23) Clinical Interview Schedule and ========>(N = 15) DSM-III Symptom Checklist by Psychiatrist ====> HSR+ (N = 1) Cases (N = 1) Non-cases (N = 1) POST-TRAINING HSR** completed by primary' care worker independently SRQ (N = 27) 1-HSR (N = 1) Recruited Subjects (N = 100) SRQ SRQ* administered by research team ====> HSR+ (N = ?) Cases (N ;:; 1) Non-cases (N = ?) Self Reporting Questionnaire; ** HSR** completed by primary care worker independently SRQ (N = 63) 1-HSR (N = ?) HSR ;:; Health Staff Review ," I


FIGURE 4 (continued) EXISTING DATA ECUADOR PRE-TRAINING AND POST-TRAINING PRELIMINARY MAIN FINDINGS: High prevalence of of emotional distress among emotional care workers ADDITIONAL ANALYSES TO BE DONE: Frequency of specific DSM-III diagnoses Relationship between SRQ and DSM III diagnoses Predictors of specific diagnoses by SRQ results Phenomenology of subclinical conditions Hierarchy of diagnoses Utilization of health 'and mental health services Detection of patients with emotional problems by primary care worker in comparison to psychiatric diagnoses Probe into issues of disaster exposure as sample includes subjects who have been affected by the disaster in different ways Changes in detection of emotional distress by the primary care worker secondary to training courses completion of pre-training and post-training detection rates


:z W U et:: W c... __ &0 80 70 .' 60+ t'. \ .' q \ 1 I .' 50t \"'{ .. I \ I -\// \ I 40+ \,. 30 20 10 .. \ \ \ \ I I \ I I '\i :'\ ''''''c. \, \ o I I I I I I I I I I I I I I I I .I I I I I Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14 Q16 Q17 Q18 Q19 Q20 ITEMS OF THE SELF-WqRTII'-!G QUESTIONNAIRE. Izj t-I Cil d I:d tzj VI


Figure 5. Symptom profile of victims with emotional disttess as defined by the Self-Reporting Questionnaire in tent camps in Armero (N=lll) and in primary care clinics in Armero (N-4S) and Ecuador (N .. 60). Armero tens Armero Clinics Ecuador See appendix for individual symptoms of the Self-Reporting QuestiQnnaire.


APPENDIX Items of the Self-Reporting Questionnaire 1. Do you often have headaches? 2. Is your appetite poor? 3.00 you sleep badly? 4. Are you easily 5. Do your hands shake? 6. Do you feel nervous, tense, or 7. Is your digestion poor? B. Do you have trouble thinking clearly? 9. Do you feel unhappy? 10. Do you cry more than usual? 11. Do you find it difficult to enjoy your daily activities? 12. Do you find it difficult to make decisions? 13. Is your daily work suffering? 14. Are you unable to playa useful part in life? 15. Have you lost interest in things? 16. Do you feel that you are a worthless person? 17. Has the thought of enpingyour life been in your mind? lB. Do you feel tired all the time? 19. Do you have uncomfortable feelings in your stomach? 20. Are you easily tired?

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b the experience in Ecuador, April 6-11, 1987 : final report /
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Natural Hazards Research and Applications Information Center, University of Colorado,
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Psychological aspects.
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