539236 research-article2014
ANP0010.1177/0004867414539236Australian & New Zealand Journal of PsychiatryMcFarlane and Van Hooff
Viewpoint Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(7) 600–602 DOI: 10.1177/0004867414539236
Learning for the future: The challenge of disaster research
© The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Alexander C McFarlane and Miranda Van Hooff
A striking finding of the Black Saturday Royal Commission was the failure to learn from the experiences of the Ash Wednesday bushfire disasters in 1983, particularly in terms of giving timely warning of the approaching cold front that led to the deaths of the substantial majority of people (Teague et al., 2010). Disasters are infrequent events. It is therefore critical that lessons are learned from previous experience and are not forgotten. Norris (2006: 173) highlighted a worrying trend in disaster research. She reviewed 225 disaster studies over a period of two decades and concluded that ‘certain desirable characteristics (longitudinal designs, representative samples) have been decreasing in prevalence over time whereas others (early assessment) have been increasing’. Against this background, and in light of the current research being conducted into the psychological morbidity following the Black Saturday bushfires in Victoria (Bryant et al., 2014), it is important to reflect on the history of mental health research into disasters in both Australia and, more broadly, internationally. Disasters are a focal point of psychiatric research for a number of reasons. First, they provide a unique opportunity to examine the differential effects of a single traumatic event on an entire population, allowing the modelling of the risk factors and characteristics of resilience in the affected population. The 1983 Ash Wednesday bushfires (McFarlane, 1990) provided an early opportunity to investigate the role of personality, subsequent
adversity, family history of psychiatric disorder, and avoidant coping, which are now widely accepted as general risk factors for posttraumatic stress disorder (PTSD) from the result of several meta-analyses (Brewin et al., 2000; Ozer et al., 2003). It is important that future disaster studies develop novel questions and do not answer questions that are well documented in the literature. A unique opportunity arose to conduct a study of this quality in the aftermath of the Canberra bushfires (Parslow et al., 2006). This disaster occurred in the setting where a cohort of 2085 young adults had been opportunistically surveyed prior to the fire and were then re-interviewed some 3–18 months post disaster. Of the individuals exposed to the fire, female gender, lower education level, poorer mental health and higher levels of neuroticism prior to the trauma were significant risk factors for PTSD symptoms post trauma. This unique study was able to quantify the relative contributions of individual risk factors in contrast to bushfire-related trauma exposures, highlighting the importance of the trauma threat and reactions to the trauma. The contributions of such pre/post-trauma studies are unique in that they address the confounds of cause and effect that typically exist in risk factor modelling study designs. Disasters also provide an opportunity to monitor the magnitude of morbidity from a public health perspective and to provide insights into the effectiveness of the mental health
interventions provided. Studies such as those of the recent Black Saturday bushfires (Bryant et al., 2014) provide important insights into the effectiveness of service delivery in the aftermath of disasters in Australia and whether this has improved significantly over time, both in terms of accessibility and the quality of the interventions offered. Such research is important to ensure that the overwhelming assistance provided in the post-disaster environment adequately addresses the immediate needs of the community (McFarlane and Raphael, 1984). Early research following up survivors of the Newcastle earthquake of 1989 (Carr et al., 1992) carefully mapped longitudinal patterns of service utilisation over a 2-year period (Carr et al., 1997). This research highlights the need to concentrate on improving health outcomes for disaster victims who remain symptomatic despite receiving care. Equally, it is essential to develop better ways of screening populations for psychiatric disorders following disaster exposure in order to improve access to care. A study of London 7/7 bombing victims, for example, identified that general practitioners who were consulted in
Centre for Traumatic Stress Studies, The University of Adelaide, Adelaide, Australia Corresponding author: Alexander McFarlane, Centre for Traumatic Stress Studies, Level 2, 122 Frome St, Adelaide, SA 5000, Australia. Email: [email protected]
Australian & New Zealand Journal of Psychiatry, 48(7) Downloaded from anp.sagepub.com at UNIV OF NORTH DAKOTA on May 31, 2015
601
McFarlane and Van Hooff the aftermath of this disaster often underestimated the significance of people’s symptoms and the potential benefits from treatment (Brewin et al., 2008). Studies that audit the effectiveness of primary care networks are critical in the aftermath of future disasters if the quality of health care is to be improved. Disasters also provide a particular opportunity to investigate the health and well-being of at-risk groups, in particular those who put themselves at risk to protect the broader community. The pioneering work of Raphael (1977) with police officers following the Granville train disaster, for example, provided important insight into the significant risks of disaster exposure to the mental health of emergency service workers. Further, the longitudinal study of McFarlane and Papay (1992) of fire fighters following the Ash Wednesday bushfires highlighted the potential chronicity and the patterns of comorbidity that can occur in those who put their lives at risk for defending the community (McFarlane, 1986; McFarlane and Papay, 1992). In an era when there are attempts to curtail and limit compensation payments for psychological injuries, such research is of critical importance in highlighting the need to frame compensation differently for emergency service workers. The likely chronicity of their morbidity, brought about by their ongoing exposure to multiple traumatic events and the substantial levels of disability associated with PTSD (Byers et al., 2014), further support the need to give special consideration to this at-risk population. If restrictions are going to be made in legislative changes to compensation systems, the issue of high-risk occupational exposures demands particular attention. It is possible that individuals will not be willing to take on these critical roles in the public interest if they are not fully protected from the hazards associated with their occupation. Disasters allow an examination of the impact of traumatic events on the developmental vulnerabilities of
children. A population of children exposed to the Ash Wednesday bushfires has now been followed for 28 years (McFarlane and Van Hooff, 2009). Similar to the study of Bryant et al. (2014), this study cautioned against viewing the disaster in isolation from the substantial prevalence of traumatic events that occur within the broader Australian community and background psychological morbidity of the disaster victim. Whilst there appeared to be significant long-term educational and socio-economic disadvantage, the only significant difference in relation to psychiatric disorder when compared to a non-exposed comparison group was a greater prevalence of weather phobia in the bushfire-exposed group arising from the extreme wind conditions on the day of the fire. The fire-affected community was also at greater risk of rape and sexual molestation in the aftermath, highlighting the way in which traumatic exposures in disasters can change selfprotective behaviours in a community. Hence, the long-term impact of disasters needs to be viewed in the context of the broad range of traumatic experiences that impact our society as the latter are less visible in the public eye but demand equal attention from a public health perspective. Finally, disasters provide an opportunity to map across time the willingness of the Australian population to become involved in mental health research. This is graphically highlighted in the 16% response rate obtained by Bryant et al. (2014) compared with the 52% response rate obtained using similar methodology in previous studies (McFarlane et al., 1997). Increasingly strict interpretations of privacy legislation controlling medical research is somewhat paradoxical (Loff et al., 2013), particularly in a day and age when individuals’ emails are being systematically analysed and used without consent by Internet service providers to target advertising. Medical research, which is ultimately for the public good, is subject to high levels of scrutiny and
potential prohibition in contrast to the accessibility of Facebook and the plundering of information by advertisers. The frequency of unsolicited satisfaction surveys is a further disincentive for people to engage in epidemiological research due to survey fatigue. A comparison of these response rates across time between two similar populations highlights the increasing need for there to be a highlevel debate about how to protect individual privacy in the context of a capacity to form high-quality epidemiological research, two aims which are becoming increasingly contradictory. The field of traumatic stress has reached a significant level of maturity since the introduction of PTSD as a diagnostic category in 1980. Disasters are a unique class of traumatic events because of the large numbers of individuals affected simultaneously and the community interest that they evoke. The infrequent nature of these events makes it critical that the lessons learned after one event are passed on to protect the next generation. The flood of information brought about by modern technology and electronic publishing can readily dilute the visibility of lessons that have been previously learnt. It is important to scan the past horizon and to hang on to hard learned lessons. The Black Saturday bushfires are a salutary lesson on how forgetting carries with it a great cost. Psychiatric research plays an important role in maintaining the long-term public interest in the aftermath of these disasters when the short attention span of the media has often long forgotten the suffering of these communities. Such research can be used not only to better the lives of those affected by the recent disaster but to generally improve the quality of mental health services provided in the long term in the regions affected. Keywords Disaster, post-traumatic stress disorder, bushfires
Australian & New Zealand Journal of Psychiatry, 48(7)
Downloaded from anp.sagepub.com at UNIV OF NORTH DAKOTA on May 31, 2015
602 Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Brewin CR, Andrews B and Valentine JD (2000) Meta-analysis of risk factors for posttraumatic stress disorder in trauma exposed adults. Journal of Consulting and Clinical Psychology 68: 748–766. Brewin CR, Scragg P, Robertson M, et al. (2008) Promoting mental health following the London bombings: A screen and treat approach. Psychosocial Steering Group, London Bombings Trauma Response Programme. Journal of Traumatic Stress 21: 3–8. Bryant RA, Waters E, Gibbs L, et al. (2014) Psychological outcomes following the Victorian Black Saturday bushfires. Australian and New Zealand Journal of Psychiatry 48: 634–643. Byers AL, Covinsky KE, Neylan TC, et al. (2014) Chronicity of posttraumatic stress disorder and risk of disability in older persons. JAMA
ANZJP Perspectives Psychiatry. Epub ahead of print 19 Mar. DOI: 10.1001/jamapsychiatry.2014.5. Carr VJ, Lewin TJ, Carter GL, et al. (1992) Patterns of service utilisation following the 1989 Newcastle earthquake: Findings from phase 1 of the Quake Impact Study. Australian Journal of Public Health 16: 360–369. Carr VJ, Lewin TJ, Webster RA, et al. (1997) A synthesis of the findings from the Quake Impact Study: A two-year investigation of the psychosocial sequelae of the 1989 Newcastle earthquake. Social Psychiatry and Psychiatric Epidemiology 32: 123–136. Loff B, Campbell EA, Glass DC, et al. (2013) Access to the Commonwealth electoral roll for medical research. Medical Journal of Australia 199: 128–130. McFarlane AC (1986) Long-term psychiatric morbidity after a natural disaster. Implications for disaster planners and emergency services. Medical Journal of Australia 145: 561–563. McFarlane AC (1990) An Australian disaster: The 1983 bushfires. International Journal of Mental Health 19: 36–47. McFarlane AC and Papay P (1992) Multiple diagnoses in posttraumatic stress disorder in the victims of a natural disaster. Journal of Nervous and Mental Disorders 180: 498–504. McFarlane AC and Raphael B (1984) Ash Wednesday: The effects of a fire. Australian and New Zealand Journal of Psychiatry 18: 341–351.
McFarlane AC and Van Hooff M (2009) Impact of childhood exposure to a natural disaster on adult mental health: 20-year longitudinal follow-up study. British Journal of Psychiatry 195: 142–148. Erratum in: British Journal of Psychiatry 2009; 195: 371. McFarlane AC, Clayer JR and Bookless CL (1997) Psychiatric morbidity following a natural disaster: An Australian bushfire. Social Psychiatry and Psychiatric Epidemiology 32: 261–268. Norris FH (2006) Disaster research methods: Past progress and future directions. Journal of Traumatic Stress 19: 173–184. Ozer EJ, Best SR, Lipsey TL, et al (2003) Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin 129: 552–573. Parslow RA, Jorm AF and Christensen H (2006) Associations of pre-trauma attributes and trauma exposure with screening positive for PTSD: Analysis of a community-based study of 2085 young adults. Psychological Medicine 36: 387–395. Raphael B (1977) The Granville train disaster: Psychological needs and their management. Medical Journal of Australia 1: 303–305. Teague B, McLeod R and Pascoe S (2010) 2009 Victorian Bushfires Royal Commission , Final Report, 2010. Government Printer for the State of Victoria. Available at: www.royalcommission. vic.gov.au/finaldocuments/summary/pf/vbrc.
Australian & New Zealand Journal of Psychiatry, 48(7) Downloaded from anp.sagepub.com at UNIV OF NORTH DAKOTA on May 31, 2015
ANP0010.1177/0004867414539236Australian & New Zealand Journal of PsychiatryMcFarlane and Van Hooff
Viewpoint Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(7) 600–602 DOI: 10.1177/0004867414539236
Learning for the future: The challenge of disaster research
© The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Alexander C McFarlane and Miranda Van Hooff
A striking finding of the Black Saturday Royal Commission was the failure to learn from the experiences of the Ash Wednesday bushfire disasters in 1983, particularly in terms of giving timely warning of the approaching cold front that led to the deaths of the substantial majority of people (Teague et al., 2010). Disasters are infrequent events. It is therefore critical that lessons are learned from previous experience and are not forgotten. Norris (2006: 173) highlighted a worrying trend in disaster research. She reviewed 225 disaster studies over a period of two decades and concluded that ‘certain desirable characteristics (longitudinal designs, representative samples) have been decreasing in prevalence over time whereas others (early assessment) have been increasing’. Against this background, and in light of the current research being conducted into the psychological morbidity following the Black Saturday bushfires in Victoria (Bryant et al., 2014), it is important to reflect on the history of mental health research into disasters in both Australia and, more broadly, internationally. Disasters are a focal point of psychiatric research for a number of reasons. First, they provide a unique opportunity to examine the differential effects of a single traumatic event on an entire population, allowing the modelling of the risk factors and characteristics of resilience in the affected population. The 1983 Ash Wednesday bushfires (McFarlane, 1990) provided an early opportunity to investigate the role of personality, subsequent
adversity, family history of psychiatric disorder, and avoidant coping, which are now widely accepted as general risk factors for posttraumatic stress disorder (PTSD) from the result of several meta-analyses (Brewin et al., 2000; Ozer et al., 2003). It is important that future disaster studies develop novel questions and do not answer questions that are well documented in the literature. A unique opportunity arose to conduct a study of this quality in the aftermath of the Canberra bushfires (Parslow et al., 2006). This disaster occurred in the setting where a cohort of 2085 young adults had been opportunistically surveyed prior to the fire and were then re-interviewed some 3–18 months post disaster. Of the individuals exposed to the fire, female gender, lower education level, poorer mental health and higher levels of neuroticism prior to the trauma were significant risk factors for PTSD symptoms post trauma. This unique study was able to quantify the relative contributions of individual risk factors in contrast to bushfire-related trauma exposures, highlighting the importance of the trauma threat and reactions to the trauma. The contributions of such pre/post-trauma studies are unique in that they address the confounds of cause and effect that typically exist in risk factor modelling study designs. Disasters also provide an opportunity to monitor the magnitude of morbidity from a public health perspective and to provide insights into the effectiveness of the mental health
interventions provided. Studies such as those of the recent Black Saturday bushfires (Bryant et al., 2014) provide important insights into the effectiveness of service delivery in the aftermath of disasters in Australia and whether this has improved significantly over time, both in terms of accessibility and the quality of the interventions offered. Such research is important to ensure that the overwhelming assistance provided in the post-disaster environment adequately addresses the immediate needs of the community (McFarlane and Raphael, 1984). Early research following up survivors of the Newcastle earthquake of 1989 (Carr et al., 1992) carefully mapped longitudinal patterns of service utilisation over a 2-year period (Carr et al., 1997). This research highlights the need to concentrate on improving health outcomes for disaster victims who remain symptomatic despite receiving care. Equally, it is essential to develop better ways of screening populations for psychiatric disorders following disaster exposure in order to improve access to care. A study of London 7/7 bombing victims, for example, identified that general practitioners who were consulted in
Centre for Traumatic Stress Studies, The University of Adelaide, Adelaide, Australia Corresponding author: Alexander McFarlane, Centre for Traumatic Stress Studies, Level 2, 122 Frome St, Adelaide, SA 5000, Australia. Email: [email protected]
Australian & New Zealand Journal of Psychiatry, 48(7) Downloaded from anp.sagepub.com at UNIV OF NORTH DAKOTA on May 31, 2015
601
McFarlane and Van Hooff the aftermath of this disaster often underestimated the significance of people’s symptoms and the potential benefits from treatment (Brewin et al., 2008). Studies that audit the effectiveness of primary care networks are critical in the aftermath of future disasters if the quality of health care is to be improved. Disasters also provide a particular opportunity to investigate the health and well-being of at-risk groups, in particular those who put themselves at risk to protect the broader community. The pioneering work of Raphael (1977) with police officers following the Granville train disaster, for example, provided important insight into the significant risks of disaster exposure to the mental health of emergency service workers. Further, the longitudinal study of McFarlane and Papay (1992) of fire fighters following the Ash Wednesday bushfires highlighted the potential chronicity and the patterns of comorbidity that can occur in those who put their lives at risk for defending the community (McFarlane, 1986; McFarlane and Papay, 1992). In an era when there are attempts to curtail and limit compensation payments for psychological injuries, such research is of critical importance in highlighting the need to frame compensation differently for emergency service workers. The likely chronicity of their morbidity, brought about by their ongoing exposure to multiple traumatic events and the substantial levels of disability associated with PTSD (Byers et al., 2014), further support the need to give special consideration to this at-risk population. If restrictions are going to be made in legislative changes to compensation systems, the issue of high-risk occupational exposures demands particular attention. It is possible that individuals will not be willing to take on these critical roles in the public interest if they are not fully protected from the hazards associated with their occupation. Disasters allow an examination of the impact of traumatic events on the developmental vulnerabilities of
children. A population of children exposed to the Ash Wednesday bushfires has now been followed for 28 years (McFarlane and Van Hooff, 2009). Similar to the study of Bryant et al. (2014), this study cautioned against viewing the disaster in isolation from the substantial prevalence of traumatic events that occur within the broader Australian community and background psychological morbidity of the disaster victim. Whilst there appeared to be significant long-term educational and socio-economic disadvantage, the only significant difference in relation to psychiatric disorder when compared to a non-exposed comparison group was a greater prevalence of weather phobia in the bushfire-exposed group arising from the extreme wind conditions on the day of the fire. The fire-affected community was also at greater risk of rape and sexual molestation in the aftermath, highlighting the way in which traumatic exposures in disasters can change selfprotective behaviours in a community. Hence, the long-term impact of disasters needs to be viewed in the context of the broad range of traumatic experiences that impact our society as the latter are less visible in the public eye but demand equal attention from a public health perspective. Finally, disasters provide an opportunity to map across time the willingness of the Australian population to become involved in mental health research. This is graphically highlighted in the 16% response rate obtained by Bryant et al. (2014) compared with the 52% response rate obtained using similar methodology in previous studies (McFarlane et al., 1997). Increasingly strict interpretations of privacy legislation controlling medical research is somewhat paradoxical (Loff et al., 2013), particularly in a day and age when individuals’ emails are being systematically analysed and used without consent by Internet service providers to target advertising. Medical research, which is ultimately for the public good, is subject to high levels of scrutiny and
potential prohibition in contrast to the accessibility of Facebook and the plundering of information by advertisers. The frequency of unsolicited satisfaction surveys is a further disincentive for people to engage in epidemiological research due to survey fatigue. A comparison of these response rates across time between two similar populations highlights the increasing need for there to be a highlevel debate about how to protect individual privacy in the context of a capacity to form high-quality epidemiological research, two aims which are becoming increasingly contradictory. The field of traumatic stress has reached a significant level of maturity since the introduction of PTSD as a diagnostic category in 1980. Disasters are a unique class of traumatic events because of the large numbers of individuals affected simultaneously and the community interest that they evoke. The infrequent nature of these events makes it critical that the lessons learned after one event are passed on to protect the next generation. The flood of information brought about by modern technology and electronic publishing can readily dilute the visibility of lessons that have been previously learnt. It is important to scan the past horizon and to hang on to hard learned lessons. The Black Saturday bushfires are a salutary lesson on how forgetting carries with it a great cost. Psychiatric research plays an important role in maintaining the long-term public interest in the aftermath of these disasters when the short attention span of the media has often long forgotten the suffering of these communities. Such research can be used not only to better the lives of those affected by the recent disaster but to generally improve the quality of mental health services provided in the long term in the regions affected. Keywords Disaster, post-traumatic stress disorder, bushfires
Australian & New Zealand Journal of Psychiatry, 48(7)
Downloaded from anp.sagepub.com at UNIV OF NORTH DAKOTA on May 31, 2015
602 Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Brewin CR, Andrews B and Valentine JD (2000) Meta-analysis of risk factors for posttraumatic stress disorder in trauma exposed adults. Journal of Consulting and Clinical Psychology 68: 748–766. Brewin CR, Scragg P, Robertson M, et al. (2008) Promoting mental health following the London bombings: A screen and treat approach. Psychosocial Steering Group, London Bombings Trauma Response Programme. Journal of Traumatic Stress 21: 3–8. Bryant RA, Waters E, Gibbs L, et al. (2014) Psychological outcomes following the Victorian Black Saturday bushfires. Australian and New Zealand Journal of Psychiatry 48: 634–643. Byers AL, Covinsky KE, Neylan TC, et al. (2014) Chronicity of posttraumatic stress disorder and risk of disability in older persons. JAMA
ANZJP Perspectives Psychiatry. Epub ahead of print 19 Mar. DOI: 10.1001/jamapsychiatry.2014.5. Carr VJ, Lewin TJ, Carter GL, et al. (1992) Patterns of service utilisation following the 1989 Newcastle earthquake: Findings from phase 1 of the Quake Impact Study. Australian Journal of Public Health 16: 360–369. Carr VJ, Lewin TJ, Webster RA, et al. (1997) A synthesis of the findings from the Quake Impact Study: A two-year investigation of the psychosocial sequelae of the 1989 Newcastle earthquake. Social Psychiatry and Psychiatric Epidemiology 32: 123–136. Loff B, Campbell EA, Glass DC, et al. (2013) Access to the Commonwealth electoral roll for medical research. Medical Journal of Australia 199: 128–130. McFarlane AC (1986) Long-term psychiatric morbidity after a natural disaster. Implications for disaster planners and emergency services. Medical Journal of Australia 145: 561–563. McFarlane AC (1990) An Australian disaster: The 1983 bushfires. International Journal of Mental Health 19: 36–47. McFarlane AC and Papay P (1992) Multiple diagnoses in posttraumatic stress disorder in the victims of a natural disaster. Journal of Nervous and Mental Disorders 180: 498–504. McFarlane AC and Raphael B (1984) Ash Wednesday: The effects of a fire. Australian and New Zealand Journal of Psychiatry 18: 341–351.
McFarlane AC and Van Hooff M (2009) Impact of childhood exposure to a natural disaster on adult mental health: 20-year longitudinal follow-up study. British Journal of Psychiatry 195: 142–148. Erratum in: British Journal of Psychiatry 2009; 195: 371. McFarlane AC, Clayer JR and Bookless CL (1997) Psychiatric morbidity following a natural disaster: An Australian bushfire. Social Psychiatry and Psychiatric Epidemiology 32: 261–268. Norris FH (2006) Disaster research methods: Past progress and future directions. Journal of Traumatic Stress 19: 173–184. Ozer EJ, Best SR, Lipsey TL, et al (2003) Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin 129: 552–573. Parslow RA, Jorm AF and Christensen H (2006) Associations of pre-trauma attributes and trauma exposure with screening positive for PTSD: Analysis of a community-based study of 2085 young adults. Psychological Medicine 36: 387–395. Raphael B (1977) The Granville train disaster: Psychological needs and their management. Medical Journal of Australia 1: 303–305. Teague B, McLeod R and Pascoe S (2010) 2009 Victorian Bushfires Royal Commission , Final Report, 2010. Government Printer for the State of Victoria. Available at: www.royalcommission. vic.gov.au/finaldocuments/summary/pf/vbrc.
Australian & New Zealand Journal of Psychiatry, 48(7) Downloaded from anp.sagepub.com at UNIV OF NORTH DAKOTA on May 31, 2015
