Mood Disorders
How much of the population is affected by mood disorders?
What causes mood disorders / mental illness?
Are mood disorders treatable?
What are some common mood disorders?
More information about bipolar disorder: description; symptoms; formal diagnosis;
treatment
More information about depression: description; symptoms; formal diagnosis;
treatment
For more information and referrals
How much of the population is affected by mood disorders?
Each year, almost 44 million Americans experience a mental disorder. In fact, mental illnesses are among the most common conditions affecting health today.
What causes mood disorders / mental illness?
Researchers believe most serious mental illnesses are caused by complex imbalances in the brain's chemical activity. They also believe environmental factors can play a part in triggering, or cushioning against, the onset of mental illness.
Are mood disorders treatable?
Like other diseases, mental illnesses can be treated. The good news is that most people who have mental illnesses, even serious ones, can lead productive lives with proper treatment. Mood disorders are one form of serious mental illness.
What are some common mood disorders?
Two of the most common mood disorders are depression and bipolar disorder, also known as manic-depressive illness.
Bipolar Disorder
Description:
Extreme mood swings punctuated by periods of generally even-keeled behavior characterize this disorder. Bipolar disorder tends to run in families. This disorder typically begins in the mid-twenties and continues throughout life. Without treatment, people who have bipolar disorder often go through devastating life events such as marital breakups, job loss, substance abuse, and suicide.
Symptoms:
Mania-expansive or irritable mood, inflated self-esteem, decreased need for sleep; increased energy; racing thoughts; feelings of invulnerability; poor judgment; heightened sex drive; and denial that anything is wrong. Depression-feelings of hopelessness, guilt, worthlessness, or melancholy; fatigue; loss of appetite for food or sex; sleep disturbances, thoughts of death or suicide; and suicide attempts. Mania and depression may vary in both duration and degree of intensity.
Formal Diagnosis:
Although scientific evidence indicates bipolar disorder is caused by chemical imbalances in the brain, no lab test exists to diagnose the disorder. In fact, this mental illness often goes unrecognized by the person who has it, relatives, friends, or even physicians. The first step of diagnosis is to receive a complete medical evaluation to rule out any other mental or physical disorders. Anyone who has this mental illness should be under the care of a psychiatrist skilled in the diagnosis and treatment of bipolar disorder.
Treatment:
Eighty to ninety percent of people who have bipolar disorder can be treated effectively with medication and psychotherapy. Self-help groups can offer emotional support and assistance in recognizing signs of relapse to avert a full-blown episode of bipolar disorder. The most commonly prescribed medications to treat bipolar disorder are three mood stabilizers: lithium carbonate, carbamazepine, and valproate.
Depression
Description:
When a person's feelings of sadness persist beyond a few weeks, he or she may have depression. According to the National Institute for Mental Health, three to four million men are affected by depression; it affects twice as many women. Researchers do not know the exact mechanisms that trigger depression. Two neurotransmitters-natural substances that allow brain cells to communicate with one another-are implicated in depression: serotonin and norepinephrine.
Symptoms:
Changes in appetite and sleeping patterns; feelings of worthlessness, hopelessness, and inappropriate guilt; loss of interest or pleasure in formerly important activities; fatigue; inability to concentrate; overwhelming sadness; disturbed thinking; physical symptoms such as headaches or stomachaches; and suicidal thoughts or behaviors.
Formal Diagnosis:
Four or more of the previous symptoms have been present continually, or most of the time, for more than 2 weeks. The term clinical depression merely means the episode of depression is serious enough to require treatment. Major depression is marked by far more severe symptoms, such as literally being unable to drag oneself out of bed. Another form of depression, known as seasonal affective disorder, is associated with seasonal changes in the amount of available daylight.
Treatment:
Some types of cognitive/behavioral therapy and interpersonal therapy may be as effective as medications for some people who have depression. Special bright light helps many people who have seasonal affective disorder.
Three major types of medication are used to treat depression: tricyclics; the newer selective serotonin re-uptake inhibitors (SSRIs), and monoamine oxidase inhibitors (MAO inhibitors). Electroconvulsive therapy uses small amounts of electricity applied to the scalp to affect neurotransmitters in the brain. Usually referred to as ECT, this highly controversial and potentially life-saving technique is considered only when other therapies have failed, when a person is seriously medically ill and/or unable to take medication, or when a person is very likely to commit suicide. Substantial improvements in the equipment, dosing guidelines and anesthesia have significantly reduced the possibility of side effects.
For more information and referrals to specialists and self-help groups in your State, contact:
Depression and Bipolar Support Alliance (DBSA)
(formerly the National Depressive and Manic-Depressive Association)
730 N. Franklin Street, Suite 501
Chicago, IL 60601-3526
Telephone: 800-826-3632
Fax: 312-642-7243
www.dbsalliance.org
Note: These are suggested resources. It is not meant to be a complete list.
May 19, 2010
May 18, 2010
National Strategy for Suicide Prevention
National Strategy for Suicide Prevention:
Goals and Objectives for Action
--------------------------------------------------------------------------------
Preface from the Surgeon General:
Suicide exacts an enormous toll from the American people. Our Nation loses 30,000 lives to this tragedy each year, another 650,000 receive emergency care after attempting to take their own lives. The devastating trauma, loss, and suffering is multiplied in the lives of family members and friends. This document, National Strategy for Suicide Prevention – Goals and Objectives for Action, lays the foundation of our Nation's strategy to confront this serious public health problem.
At this document's source are countless dedicated individuals representing every facet of our Nation's communities. They include representatives to a 1993 United Nations/World Health Organization Conference who played key roles in establishing guidelines for national suicide prevention strategies. They include the passionate grassroots activists whose work stimulated Congressional Resolutions declaring suicide prevention a national priority and calling for our own national strategy. They include dedicated public servants and private individuals who jointly organized and participated in the first National Suicide Prevention Conference in 1998 to consolidate a scientific base for this critical endeavor. These people and their efforts led directly to publication of the Surgeon General's Call to Action to Prevent Suicide - 1999 with its most important recommendation, the completion of the National Strategy for Suicide Prevention.
After listening to the concerns of the American people, Government leaders helped bring stakeholders together in a shining example of public- private collaboration to achieve this major milestone in public health. Those who have invested their hearts and minds in this effort believe it effectively points the way for organizations and individuals to curtail the tragedy of suicide and suicidal behavior. Though it does not specify all the details, it provides essential guidance and suggests the fundamental activities that must follow–activities based on the best available science.
Nearly half of the States are engaged in suicide prevention and many have already committed significant resources to implement programs. Their leadership in evaluating the effectiveness of these programs will help guide the efforts of States that follow in their paths. Most of these plans recognize that much of the work of suicide prevention must occur at the community level, where human relationships breathe life into public policy. American communities are also home to scores of faith-based and secular initiatives that help reduce risk factors and promote protective factors associated with many of our most pressing social problems, including suicide.
As you read further, keep in mind that the National Strategy for Suicide Prevention is not the Surgeon General's strategy or the Federal government's strategy; rather, it is the strategy of the American people for improving their health and well-being through the prevention of suicide. I congratulate each person who played a role in bringing it to completion. You have served your fellow Americans well.
Sincerely yours,
David Satcher, M.D., Ph.D.
Surgeon General
Goals and Objectives for Action
--------------------------------------------------------------------------------
Preface from the Surgeon General:
Suicide exacts an enormous toll from the American people. Our Nation loses 30,000 lives to this tragedy each year, another 650,000 receive emergency care after attempting to take their own lives. The devastating trauma, loss, and suffering is multiplied in the lives of family members and friends. This document, National Strategy for Suicide Prevention – Goals and Objectives for Action, lays the foundation of our Nation's strategy to confront this serious public health problem.
At this document's source are countless dedicated individuals representing every facet of our Nation's communities. They include representatives to a 1993 United Nations/World Health Organization Conference who played key roles in establishing guidelines for national suicide prevention strategies. They include the passionate grassroots activists whose work stimulated Congressional Resolutions declaring suicide prevention a national priority and calling for our own national strategy. They include dedicated public servants and private individuals who jointly organized and participated in the first National Suicide Prevention Conference in 1998 to consolidate a scientific base for this critical endeavor. These people and their efforts led directly to publication of the Surgeon General's Call to Action to Prevent Suicide - 1999 with its most important recommendation, the completion of the National Strategy for Suicide Prevention.
After listening to the concerns of the American people, Government leaders helped bring stakeholders together in a shining example of public- private collaboration to achieve this major milestone in public health. Those who have invested their hearts and minds in this effort believe it effectively points the way for organizations and individuals to curtail the tragedy of suicide and suicidal behavior. Though it does not specify all the details, it provides essential guidance and suggests the fundamental activities that must follow–activities based on the best available science.
Nearly half of the States are engaged in suicide prevention and many have already committed significant resources to implement programs. Their leadership in evaluating the effectiveness of these programs will help guide the efforts of States that follow in their paths. Most of these plans recognize that much of the work of suicide prevention must occur at the community level, where human relationships breathe life into public policy. American communities are also home to scores of faith-based and secular initiatives that help reduce risk factors and promote protective factors associated with many of our most pressing social problems, including suicide.
As you read further, keep in mind that the National Strategy for Suicide Prevention is not the Surgeon General's strategy or the Federal government's strategy; rather, it is the strategy of the American people for improving their health and well-being through the prevention of suicide. I congratulate each person who played a role in bringing it to completion. You have served your fellow Americans well.
Sincerely yours,
David Satcher, M.D., Ph.D.
Surgeon General
May 12, 2010
Depression and Mood Disorders Continuing Education CEU
Depression and Mood Disorders
The Prevalence of Major Depression and Mood Disorders in Suicide
Mental Health: A Report of the Surgeon General, states that "major depressive disorders account for about 20 to 35 percent of all deaths by suicide" (p. 244). This estimate is based on a review of psychological autopsies conducted by Angst, Angst, and Stassen (1999). This brief review is intended to address this prevalence estimate. It is important to note that this estimate refers only to the prevalence of major depressive disorder among those who commit suicide, not any other mood disorders (e.g., bipolar I & II, dysthymia, adjustment disorder with depressed mood). Prevalence estimates that include other mood disorders in addition to major depression are much higher.
Major depression in suicide
The lower bound of the 20-35% estimate of the prevalence of major depression in suicide is loosely based on one psychological autopsy study; a study where the reliability of the diagnoses are somewhat questionable. This study (Rich, Young & Fowler, 1986) of 204 subjects identified 15% of suicides as having major depressive disorder. However, an additional 30% were reported as having "atypical depression," defined in this study as having a depressive syndrome that followed the onset of substance use. If this ambiguously defined group were to be considered major depression, the estimate climbs to 45%. A number of other studies suggest that the prevalence of major depression in suicide is somewhat over 30%. The four other available psychological autopsy studies that include samples of suicides from the full age range and reliable diagnoses based on structured interviews (Arato, Demeter, Rihmer & Somogyi, 1988; Dorpat & Ripley, 1960; Foster, Gillespie, McClelland & Patterson, 1999; Henriksson et al., 1993) obtained prevalence estimates of major depression ranging from 30-34% of suicides. In addition, several psychological autopsy studies examining more specific subsamples (e.g., the elderly, adolescents, women) find even higher prevalence estimates. In three psychological autopsy studies of adolescents (Brent et al. 1988; Brent et al., 1999; Shaffer et al., 1996) 41%, 43%, and 32% of adolescent suicides were determined to have had major depression prior to death. Two studies of young adults (Lesage et al. 1994; Runeson, 1989) found a prevalence of 40% and 41%, respectively. A study of 104 women by Asgard (1990) found a 35% rate of major depression. One study of 54 older adults over age 65 found a prevalence of 54%. In summary, the available data suggest that the 20-35% estimate for the prevalence of major depressive disorder in completed suicide is probably somewhat conservative and that a 30-40% prevalence estimate is probably more accurate. This estimate includes both secondary and primary depression. Many of these individuals would also be comorbid with other disorders, especially substance abuse.
Mood disorders in suicide
Prevalence estimates for all mood disorders in suicide (including MDD, Bipolar I & II, dysthymia, and adjustment disorder with depressed mood) are much higher than for major depression alone. These rates are probably closer to 60%, although as noted below, this estimate varies because of inconsistency of the criteria used to define a "mood disorder" across investigations. Four studies examining the full age range of suicides estimate that 36%, 48%, and 66%, and 70% of suicides have some sort of "depressive disorder" or "depression" (Foster et al., 1999; Rich et al., 1986, Henriksson et al., 1993, Barraclough, Bunch, Nelson, & Sainsbury, 1974). Three studies of adolescents found prevalence estimates for "mood disorders" or "affective disorders" of 61%, 63%, and 67% respectively (Shaffer et al., 1996; Brent et al. 1988; Marttunen et al., 1992). Two studies of young adults (Lesage et al., 1994; Runeson, 1989) found estimates of 60% and 64%. A study of 104 women by Asgard (1990) found a 59% rate of "mood disorders." In a review of psychological autopsy studies that examined patterns of psychiatric diagnosis across age groups, Conwell and Brent (1995) concluded that depressive disorders increased with age. Overall estimates for the rates of mood disorders range from 36% to 70% with great interstudy variability. This variability is probably partly a combination of unreliable methods of diagnosis and different definitions of what constitutes a "mood disorder." Despite this variability, a number of studies have found a pattern for increasing mood disorders with aging.
--------------------------------------------------------------------------------
References
Angst, J., Angst, F., and Stassen, H. H. (1999). Suicide risk in patients with major depressive disorder. Journal of Clinical Psychiatry, 60(supp. 2), 57-62.
Arato, M., Demeter, E., Rihmer, Z., & Somogyi, E. (1988). Retrospective psychiatric assessment of 200 suicides in Budapest. Acta Psychiatrica Scandinavica, 77, 454-456.
Asgard, U. (1990). A psychiatric study of suicide among urban women in Sweden. Acta Psychiatrica Scandinavica, 82, 115-124.
Barraclough, B., Bunch, J., Nelson, B., & Sainsbury, P. (1974). A hundred cases of suicide: Clinical aspects. British Journal of Psychiatry, 125,355-373.
Brent, D.A., Perper, J.A., Goldstein, C.E., Kolko, D.J., Allan, M.J., Allman, C.J., & Zelenak, J.P. (1988). Risk factors for adolescent suicide: A comparison of adolescent suicide victims with suicidal inpatients. Archives of General Psychiatry, 45,581-588.
Brent, D. A., Perper, J. A., Moritz, G., Allman, C., Friend, A., Roth, C., Schweers, J., Balach, L., & Baugher, M. (1993). Psychiatric risk factors for adolescent suicide: A case-control study. Journal of the American Academy of Child and Adolescent Psychiatry, 32,521-529.
Clark, D. C. (1991). Final Report to the AARP Adrus Foundation: Suicide Among the Elderly.
Conwell, Y. & Brent, D. (1995). Suicide and aging I: Patterns of psychiatric diagnosis. International Psychogeriatrics, 7, 149-164.
Dorpat, T. L., & Ripley, H. S. (1960). A study of suicide in the Seattle area. Comprehensive Psychiatry, 1, 349-359
Foster, T., Gillespie, K., McClelland, R., & Patterson, C. (1999). Risk factors for suicide independent of DSM-III-R Axis I disorder. British Journal of Psychiatry, 175, 175-179.
Henriksson, M. M., Aro, H. M., Marttunen, M. J., Heikkinen, M. E., Isometa, E. T., Kuoppasalmi, K. I., & Lonqvist, J. K. (1993). Mental disorders and comorbidity in suicide. American Journal of Psychiatry, 150, 935-940.
Lesage, A., Boyer, R., Grunberg, F., Vanier, C., Morissette, R., Menard-Bueeau, C., & Loyer, M. (1994). Suicide and mental disorders: A case-control study of young men. American Journal of Psychiatry, 151, 1063-1068.
Marttunen, M. J., Hillevi, M., Aro, H.M., & Lonnqvist, J. K. (1992). Adolescent suicide: Endpoint of long-term difficulties. Journal of the American Academy of Child and Adolescent Psychiatry, 34(4), 649-654.
Rich, C. L., Young, D., & Fowler, R. C. (1986). San Diego suicide study: Young vs old subjects. Archives of General Psychiatry, 43, 577-582.
Runeson, B. (1989). Mental disorder in youth suicide: DSM-III-R Axes I and II. Acta Psychiatrica Scandinavica, 79, 490-497.
Shaffer, D., Gould, M. S., Fisher, P., Trautmann, P., Moeau, D., Kleinman, M., & Flory, M. (1996). Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 53, 339-348.
The Prevalence of Major Depression and Mood Disorders in Suicide
Mental Health: A Report of the Surgeon General, states that "major depressive disorders account for about 20 to 35 percent of all deaths by suicide" (p. 244). This estimate is based on a review of psychological autopsies conducted by Angst, Angst, and Stassen (1999). This brief review is intended to address this prevalence estimate. It is important to note that this estimate refers only to the prevalence of major depressive disorder among those who commit suicide, not any other mood disorders (e.g., bipolar I & II, dysthymia, adjustment disorder with depressed mood). Prevalence estimates that include other mood disorders in addition to major depression are much higher.
Major depression in suicide
The lower bound of the 20-35% estimate of the prevalence of major depression in suicide is loosely based on one psychological autopsy study; a study where the reliability of the diagnoses are somewhat questionable. This study (Rich, Young & Fowler, 1986) of 204 subjects identified 15% of suicides as having major depressive disorder. However, an additional 30% were reported as having "atypical depression," defined in this study as having a depressive syndrome that followed the onset of substance use. If this ambiguously defined group were to be considered major depression, the estimate climbs to 45%. A number of other studies suggest that the prevalence of major depression in suicide is somewhat over 30%. The four other available psychological autopsy studies that include samples of suicides from the full age range and reliable diagnoses based on structured interviews (Arato, Demeter, Rihmer & Somogyi, 1988; Dorpat & Ripley, 1960; Foster, Gillespie, McClelland & Patterson, 1999; Henriksson et al., 1993) obtained prevalence estimates of major depression ranging from 30-34% of suicides. In addition, several psychological autopsy studies examining more specific subsamples (e.g., the elderly, adolescents, women) find even higher prevalence estimates. In three psychological autopsy studies of adolescents (Brent et al. 1988; Brent et al., 1999; Shaffer et al., 1996) 41%, 43%, and 32% of adolescent suicides were determined to have had major depression prior to death. Two studies of young adults (Lesage et al. 1994; Runeson, 1989) found a prevalence of 40% and 41%, respectively. A study of 104 women by Asgard (1990) found a 35% rate of major depression. One study of 54 older adults over age 65 found a prevalence of 54%. In summary, the available data suggest that the 20-35% estimate for the prevalence of major depressive disorder in completed suicide is probably somewhat conservative and that a 30-40% prevalence estimate is probably more accurate. This estimate includes both secondary and primary depression. Many of these individuals would also be comorbid with other disorders, especially substance abuse.
Mood disorders in suicide
Prevalence estimates for all mood disorders in suicide (including MDD, Bipolar I & II, dysthymia, and adjustment disorder with depressed mood) are much higher than for major depression alone. These rates are probably closer to 60%, although as noted below, this estimate varies because of inconsistency of the criteria used to define a "mood disorder" across investigations. Four studies examining the full age range of suicides estimate that 36%, 48%, and 66%, and 70% of suicides have some sort of "depressive disorder" or "depression" (Foster et al., 1999; Rich et al., 1986, Henriksson et al., 1993, Barraclough, Bunch, Nelson, & Sainsbury, 1974). Three studies of adolescents found prevalence estimates for "mood disorders" or "affective disorders" of 61%, 63%, and 67% respectively (Shaffer et al., 1996; Brent et al. 1988; Marttunen et al., 1992). Two studies of young adults (Lesage et al., 1994; Runeson, 1989) found estimates of 60% and 64%. A study of 104 women by Asgard (1990) found a 59% rate of "mood disorders." In a review of psychological autopsy studies that examined patterns of psychiatric diagnosis across age groups, Conwell and Brent (1995) concluded that depressive disorders increased with age. Overall estimates for the rates of mood disorders range from 36% to 70% with great interstudy variability. This variability is probably partly a combination of unreliable methods of diagnosis and different definitions of what constitutes a "mood disorder." Despite this variability, a number of studies have found a pattern for increasing mood disorders with aging.
--------------------------------------------------------------------------------
References
Angst, J., Angst, F., and Stassen, H. H. (1999). Suicide risk in patients with major depressive disorder. Journal of Clinical Psychiatry, 60(supp. 2), 57-62.
Arato, M., Demeter, E., Rihmer, Z., & Somogyi, E. (1988). Retrospective psychiatric assessment of 200 suicides in Budapest. Acta Psychiatrica Scandinavica, 77, 454-456.
Asgard, U. (1990). A psychiatric study of suicide among urban women in Sweden. Acta Psychiatrica Scandinavica, 82, 115-124.
Barraclough, B., Bunch, J., Nelson, B., & Sainsbury, P. (1974). A hundred cases of suicide: Clinical aspects. British Journal of Psychiatry, 125,355-373.
Brent, D.A., Perper, J.A., Goldstein, C.E., Kolko, D.J., Allan, M.J., Allman, C.J., & Zelenak, J.P. (1988). Risk factors for adolescent suicide: A comparison of adolescent suicide victims with suicidal inpatients. Archives of General Psychiatry, 45,581-588.
Brent, D. A., Perper, J. A., Moritz, G., Allman, C., Friend, A., Roth, C., Schweers, J., Balach, L., & Baugher, M. (1993). Psychiatric risk factors for adolescent suicide: A case-control study. Journal of the American Academy of Child and Adolescent Psychiatry, 32,521-529.
Clark, D. C. (1991). Final Report to the AARP Adrus Foundation: Suicide Among the Elderly.
Conwell, Y. & Brent, D. (1995). Suicide and aging I: Patterns of psychiatric diagnosis. International Psychogeriatrics, 7, 149-164.
Dorpat, T. L., & Ripley, H. S. (1960). A study of suicide in the Seattle area. Comprehensive Psychiatry, 1, 349-359
Foster, T., Gillespie, K., McClelland, R., & Patterson, C. (1999). Risk factors for suicide independent of DSM-III-R Axis I disorder. British Journal of Psychiatry, 175, 175-179.
Henriksson, M. M., Aro, H. M., Marttunen, M. J., Heikkinen, M. E., Isometa, E. T., Kuoppasalmi, K. I., & Lonqvist, J. K. (1993). Mental disorders and comorbidity in suicide. American Journal of Psychiatry, 150, 935-940.
Lesage, A., Boyer, R., Grunberg, F., Vanier, C., Morissette, R., Menard-Bueeau, C., & Loyer, M. (1994). Suicide and mental disorders: A case-control study of young men. American Journal of Psychiatry, 151, 1063-1068.
Marttunen, M. J., Hillevi, M., Aro, H.M., & Lonnqvist, J. K. (1992). Adolescent suicide: Endpoint of long-term difficulties. Journal of the American Academy of Child and Adolescent Psychiatry, 34(4), 649-654.
Rich, C. L., Young, D., & Fowler, R. C. (1986). San Diego suicide study: Young vs old subjects. Archives of General Psychiatry, 43, 577-582.
Runeson, B. (1989). Mental disorder in youth suicide: DSM-III-R Axes I and II. Acta Psychiatrica Scandinavica, 79, 490-497.
Shaffer, D., Gould, M. S., Fisher, P., Trautmann, P., Moeau, D., Kleinman, M., & Flory, M. (1996). Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 53, 339-348.
May 11, 2010
Suicide: Consequences
Suicide: Consequences
Cost to Society
•The total lifetime cost of self-inflicted injuries occurring in 2000 was approximately $33 billion. This includes $1 billion for medical treatment and $32 billion for lost productivity (Corso et al. 2007).
Consequences
•Suicide is the 11th leading cause of death among Americans (CDC, 2006).
•Over 33,000 people kill themselves each year (CDC, 2006).
•Approximately 395,000 people with self-inflicted injuries are treated in emergency departments each year (CDC, 2007).
•Many people are exposed to another person's suicide which may affect them psychologically. One estimate was that approximately 7% of the US population knew someone who died of suicide during the past 12 months. (Crosby and Sacks, 2002).
References
Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS). Atlanta, GA: National Center for Injury Prevention and Control. Available at: www.cdc.gov/ncipc/wisqars. Last modified 2008 August 26.
Crosby AE, Sacks JJ. Exposure to suicide: Incidence and association with suicidal ideation and behavior – United States, 1994. Suicide and Life-Threatening Behavior 2002; 32:321–328.
Corso PS, Mercy JA, Simon TR, Finkelstein EA, & Miller TR. Medical Costs and Productivity Losses Due to Interpersonal Violence and Self- Directed Violence. American Journal of Preventive Medicine 2007: 32(6): 474–482.
Cost to Society
•The total lifetime cost of self-inflicted injuries occurring in 2000 was approximately $33 billion. This includes $1 billion for medical treatment and $32 billion for lost productivity (Corso et al. 2007).
Consequences
•Suicide is the 11th leading cause of death among Americans (CDC, 2006).
•Over 33,000 people kill themselves each year (CDC, 2006).
•Approximately 395,000 people with self-inflicted injuries are treated in emergency departments each year (CDC, 2007).
•Many people are exposed to another person's suicide which may affect them psychologically. One estimate was that approximately 7% of the US population knew someone who died of suicide during the past 12 months. (Crosby and Sacks, 2002).
References
Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS). Atlanta, GA: National Center for Injury Prevention and Control. Available at: www.cdc.gov/ncipc/wisqars. Last modified 2008 August 26.
Crosby AE, Sacks JJ. Exposure to suicide: Incidence and association with suicidal ideation and behavior – United States, 1994. Suicide and Life-Threatening Behavior 2002; 32:321–328.
Corso PS, Mercy JA, Simon TR, Finkelstein EA, & Miller TR. Medical Costs and Productivity Losses Due to Interpersonal Violence and Self- Directed Violence. American Journal of Preventive Medicine 2007: 32(6): 474–482.
May 04, 2010
Family Psychoeducation
Family Psychoeducation
Workbook
Chapter 12: Readings and Other Resources
Essential Readings For Practitioners
The following four books are recommended references for those wanting to master this approach. The first includes key elements of the Anderson and Falloon approach and should be read first. The Miklowitz, et al., book is an important reference for those working with consumers with bipolar disorder.
McFarlane, W.R., Multifamily Groups in the Treatment of Severe Psychiatric Disorders, New York, NY, Guilford, 2002.
Anderson, C., Hogarty, G., Reiss, D., Schizophrenia and the Family, New York, NY, Guilford Press, 1986
Falloon, I., Boyd, J., McGill, C., Family Care of Schizophrenia, New York, NY, Guilford Press, 1984.
Miklowitz, D.J., Goldstein, M., Bipolar Disorder: A Family-focused Treatment Approach, New York, NY, Guilford Press, 1997
Additional Resources For Practitioners
Amenson, C., Schizophrenia: A Family Education Curriculum, Pacific Clinics, 1998.
Provides 150 slides with lecture notes for a class for families with a member with schizophrenia. Includes information about the illness, medication and psychosocial treatments and the role of the family in promoting recovery.
Amenson, C., Schizophrenia: Family Education Methods, Pacific Clinics, 1998.
Companion handbook to Schizophrenia: A Family Education Curriculum provides methods for forming a class, optimizing the learning of families, and dealing with typical problems that arise in conducting family classes.
Mueser K, Glynn S: Behavioral Family Therapy for Psychiatric Disorders. Oakland, New Harbinger Publications, 1999
A comprehensive model of single-Family Psychoeducation that includes a multifamily discussion/support group. The book contains individual educational handouts for various psychiatric diagnoses and handout for various related topic areas.
Psychopharmacology
The Essential Guide to Psychiatric Drugs by J. Gorman, St. Martin’s Press, 1995.
Written for a sophisticated consumer, it is the most accessible source of information about psychotropic medications. It distills the Physician’s Desk Reference into understandable language. It describes the individual “trees” (such as Prozac) in the forest of medicines. “The benzodiazepines: Are they really dangerous?” is a typical section heading.
Medicine and Mental Illness by M. Lickey and B. Gordon, Freeman, 1991.
A scholarly yet readable work written for professionals, it is best at teaching the principles of diagnosis, neurophysiology and psychopharmacological treatment of mental illness. It describes the “forest” of psychopharmacology, why it is there and how it works. “The blockade of dopamine receptors and antipsychotic potency” is a typical section heading. It does not discuss the profiles of individual medications.
Cultural Competence
The Cross-Cultural Practice of Clinical Case Management in Mental Health edited by Peter Manoleas, Haworth Press, 1996.
A collection of useful articles about the role of gender, ethnicity, and acculturation in treatment seeking and response. Provides guidelines for engaging and intervening with specific ethnic and diagnostic groups in varying treatment contexts.
Videotapes
Schizophrenia Explained by William R. McFarlane, M.D. Produced by, and order from, the author at Maine Medical Center, 22 Bramhall Street, Portland, ME 04102. (Phone 207-871-2091). mcfarw@mmc.org
This provides a full review in lay language of the psychobiology of schizophrenia, emphasizing the key concepts in Family Psychoeducation: stress reduction, optimal environments and interactions for recovery, and support for the family’s ability to contribute to recovery in many ways. It is often used in lieu of a psychiatrist during Family Education Workshops and for staffs of case management programs, community residences and employment programs to help them understand how to assist consumers with this disorder.
Exploring Schizophrenia by Christopher S. Amenson, Ph.D. Produced by the California Alliance for the Mentally Ill (Phone 916-567-0163).
This videotape uses everyday language to describe schizophrenia and give guidelines for coping with illness for consumers and their families.
Surviving and Thriving with a Mentally Ill Relative by Christopher Amenson, Ph.D., Third edition 1998.
Eighteen hours of good “home video quality” videotapes cover schizophrenia, bipolar disorder, major depressive disorder, medication, psychosocial rehabilitation, relapse prevention, motivation, and family skills. Order from Paul Burk, 1352 Hidden Springs Lane, Glendora, CA 91740. (Phone 626-335-1307).
Critical Connections: A Schizophrenia Awareness Video produced by the American Psychiatric Association, 1997.
This 30 minute video was designed by the APA to help consumers and families cope with the disabling effects of schizophrenia. It provides a hopeful, reassuring message about new medications and psychosocial treatments that assist with recovery.
Exploring Bipolar Disorder by Jerome V. Vaccaro, M.D., 1996
One hour professional quality videotape describes the illness, recovery, and the role of the family. Persons with the illness contribute valuable insights. Produced by and ordered from the California Alliance for the Mentally Ill, 1111 Howe Avenue, Suite 475, Sacramento, CA 95825. Phone 916-567-0163.
Periodicals
Schizophrenia Bulletin
Highly technical and difficult to read but it is the ultimate source for research findings. The fall 1995 issue summarizes “Treatment Outcomes Research”.
Psychiatric Services
Practical articles in all aspects of mental illness. Brief clinically relevant articles on medication and other treatments. The most useful periodical for clinical staff.
Psychosocial Rehabilitation
Practical psychosocial rehabilitation articles. Easy to read and understand. Provides “how to” details. Contains good consumer written articles.
Other Resources
There are a number of excellent books written for persons with a mental illness and their families to help them understand and deal with these illnesses. Many of these are helpful for professionals directly and all are important resources to which to refer patients and families. (See Reading List for Families.) Many of the professional and family books are offered at a discount by The National Alliance on Mental Illness, 200 N. Glebe Road, Suite 1015, Arlington, VA 22203-3754. Phone 703-524-7600.
Books on Mood Disorders (Bipolar and Unipolar Depressions)
A Brilliant Madness: Living with Manic Depressive Illness by Patty Duke and Gloria Hochman. (Bantam, 1992)
Combines personal experience with clinical information to describe manic depression in understandable terms and provide guidelines for coping with it.
Control Your Depression by Peter Lewinsohn, Ricardo Munoz, Mary Ann Youngren, and Antonette Zeiss.(Prentice Hall, Englewood Cliffs, New Jersey, 1979)
Self-help book which assesses contributors to depression and includes activities, relaxation techniques, thinking, social skills, self-control, and specific ideas and exercises for each problem area.
The Depression Workbook by Mary Ellen Copeland. (Harbinger, 1992)
Assists individuals in taking responsibility for wellness by using charts and techniques to track and control moods. The most complete and useful self help book for bipolar and unipolar depressions.
The Feeling Good Handbook by David Burns, (Penguin, New York, NY, 1989)
Self-help book presents rationale for cognitive therapy for depression. Gives specific ideas and exercises to help change thought patterns associated with depression and other problems.
Lithium and Manic Depression: A Guide by John Bohn and James Jefferson.
A very helpful guide for people with manic depression and their families regarding lithium treatment. Order from Lithium Information Center, Department of Psychiatry, University of Wisconsin, 600 Highland Ave., Madison, WI 53792.
Our Special Mom and Our Special Dad by Tootsie Sobkiewicz (Pittsburgh: Children of Mentally Ill Parents, 1994 and 1996)
Two interactive storybooks that allow primary school age children to understand and identify with the problems associated with having a mentally ill parent. Can be well utilized by a relative or therapist in individual or group work.
Overcoming Depression, Third Edition by D. & J. Papolos (Harper & Row, 1997).
A comprehensive book written for persons suffering from manic depression and major depression, as well as their families. It is the best source of information about these disorders. Does not offer coping strategies. This book and The Depression Workbook are the best two to read.
An Unquiet Mind by Kay Redfield Jamison
A compelling and emotional account of the author’s awareness, denial, and acceptance of her bipolar disorder. It offers hope and insight regarding recovery for anyone who reads it.
Books on Dual Diagnosis (Mental Illness and Substance Abuse)
Alcohol, Street Drugs, and Emotional Problems: What you need to know by B. Pepper and H. Ryglewicz.
These informative pamphlets come in versions for the client, for the family and for professionals. They can be ordered from TIE Lines, 20 Squadron Blvd. Suite 400, New York, NY 10956.
Lives at Risk: Understanding and Treating Young People with Dual Disorders by B. Pepper and H. Rygelwicz
Poignant description of the combination of schizophrenia, mood disorders, and/or personality disorders with substance abuse. Strong on empathy and understanding of the multiple problems. Provides little specific guidance.
Hazelden Publications (RW9 P.O. Box 176, Center City, MN 55012-0176 Phone 1-800-328-9000 or Website www.htbookplace.org
Publishes a large number of pamphlets and self-help books on substance abuse and dual diagnoses. Examples of titles include:
Preventing Relapse Workbook
Taking Care of Yourself: When a family member has a dual diagnosis
Twelve Steps and Dual Disorders
Understanding Schizophrenia and Addiction
Books About Children Who Have a Mental Illness
Children and Adolescents with Mental Illness: A Parents Guide by E. McElroy (Woodbine House, 1988)
Useful guide written by a psychologist who heads the NAMI Children’s and Adolescent network.
Educational Rights of Children with Disorders: A Primer for Advocates by Center for Law and Education. (Cambridge 1991.)
Neurobiological Disorders in Children and Adolescents by E. Peschel, R. Peschel and C. Howe. (Oxford Press, 1992)
Biological mental illnesses among children are less common and less understood “family problems”. This book helps to define childhood neurobiological disorders and gives guidance for finding appropriate treatment.
Books on Special Topics
Planning for the Future and the Life Planning Workbook by L. Mark Russell and Arnold Grant (American Publishing Company, 1995)
This book and accompanying workbook are guides for parents seeking to provide for the future security and happiness of an adult child with a disability following the parents’ deaths.
A Parent’s Guide to Wills and Trusts by Don Silver. (Adams-Hall, 1992)
Information on how to protect a disabled child’s financial future, written by an attorney and NAMI member.
Schizophrenia and Genetic Risks by Irving Gottesman.
This pamphlet contains detailed information about this single topic. It may be ordered from NAMI.
A Street is Not a Home: Solving American’s Homeless Dilemma by Robert Coates. (Prometheus, 1990)
Analysis and guide to dealing with homelessness among persons suffering from mental illness.
Suicide Survivors: A Guide for Those Left Behind by Adina Wrobleski. (Afterwards, 1991.)
With an understanding attitude, the author explores and offers coping suggestions for the many issues that confront families who have had a member kill himself.
Reading List For Families With A Member Who Has A Mental Illness
(Annotations by Christopher S. Amenson, Ph.D.)
Books Which Offer Guidance To Families
Coping with Schizophrenia: A Guide for Families by Kim Mueser and Susan Gingerich. (New Harbinger, 1994)
Comprehensive guide to living with schizophrenia and the best source for practical advice on topics including medication, preventing relapse, communication, family rules, drug use, and planning for the future. Includes forms and worksheets for solving typical problems.
Schizophrenia: Straight Talk for Families and Friends by Maryellen Walsh. (Morrow & Co., 1985).
A parent who, as a professional writer, thoroughly researched the field writes this book. This book is emotional in ways that will touch you and deals with all the issues important to families of persons of schizophrenia. If you can read only one book, select this one if you want to feel understood; select Understanding Schizophrenia to access current research on causes and treatments; select Coping with Schizophrenia if you want concrete advice about coping with the illness.
Surviving Schizophrenia: A Family Manual, Third Edition by E. Fuller Torrey. (Harper & Row, 1995).
Beloved by the Alliance for the Mentally Ill because it was the first book in 1983 to support and educate families. Contains one of the best descriptions of “The Inner World of Madness”. Discusses the major topics in easy to read and very pro-family language.
Troubled Journey: Coming to Terms with the Mental Illness of a Sibling or Parent by Diane Marsh and Rex Dickens (Tarcher/Putnam, 1997)
The best book for siblings and adult children. Helps to recognize and resolve the impact of mental illness on childhood. Seeks to renew self-esteem and improve current family and other relationships.
Understanding Schizophrenia: A Guide to the New Research on Causes and Treatment by Richard Keefe and Philip Harvey. (The Free Press, 1994)
The best description of research on schizophrenia as of 1994. It provides more depth and detail than Surviving Schizophrenia and is a little more difficult to read. A must for families that want to understand the science of schizophrenia.
How to Live with a Mentally Ill Person: A Handbook of Day-to-Day Strategies by Christine Adamec. (John Wiley and Sons, 1996)
This comprehensive, easy-to-read book is written by a parent. It reviews methods for accepting the illness, dealing with life issues, developing coping strategies, negotiating the mental health system, and more.
Books Describing The Experience of Schizophrenia
Anguished Voices: Siblings and Adult Children of Persons with Psychiatric Disabilities by Rex Dickens and Diane Marsh (Center for Psychiatric Rehabilitation, 1994.)
Collection of 8 well-written articles which describe the impact of mental illness on siblings and children. A poignant statement of the issues across the life span that need to be addressed when a person grows up with mental illness in the family.
Crazy Quilt by Jocelyn Riley (William Morrow, 1984)
Fictional account of a 13-year-old girl whose mother has schizophrenia. Written for children and adolescents. Provides understanding for these forgotten victims.
Is There No Place on Earth for Me? by Susan Sheehan. (Houghton-Mifflin, 1982.)
A very realistic depiction of the experience of schizophrenic woman is interwoven with information about legal, funding, and treatment issues. Gives a good description of historical and political influences on the treatment of persons suffering from schizophrenia. Won the Pulitzer Prize.
Tell Me I’m Here: One Family’s Experience with Schizophrenia by Ann Devesch. (Penquin, 1992)
Written by a United Nations Media Peace Prize winner and founder of Schizophrenia Australia, this book describes their family’s experience.
The Quiet Room by Lori Schiller. (1994)
The life story of a person who had an almost full recovery from schizophrenia with clozapine. Great for its inspirational value.
The Skipping Stone: Ripple Effects of Mental Illness on the Family by Mona Wasow (Science and Behavior Books, 1995)
Describes the impact of mental illness on each member of the family in a “Tower of Babel”. Information is from in-depth interviews with family members and professionals.
The Girl with the Crazy Brother by Betty Hyland (Franklin Watts, 1986)
Written for adolescents by an Alliance for the Mentally Ill member. Describes in short novel form the experience of a teenage girl trying to understand the sudden deterioration of her older brother.
Website resources
Workbook
Chapter 12: Readings and Other Resources
Essential Readings For Practitioners
The following four books are recommended references for those wanting to master this approach. The first includes key elements of the Anderson and Falloon approach and should be read first. The Miklowitz, et al., book is an important reference for those working with consumers with bipolar disorder.
McFarlane, W.R., Multifamily Groups in the Treatment of Severe Psychiatric Disorders, New York, NY, Guilford, 2002.
Anderson, C., Hogarty, G., Reiss, D., Schizophrenia and the Family, New York, NY, Guilford Press, 1986
Falloon, I., Boyd, J., McGill, C., Family Care of Schizophrenia, New York, NY, Guilford Press, 1984.
Miklowitz, D.J., Goldstein, M., Bipolar Disorder: A Family-focused Treatment Approach, New York, NY, Guilford Press, 1997
Additional Resources For Practitioners
Amenson, C., Schizophrenia: A Family Education Curriculum, Pacific Clinics, 1998.
Provides 150 slides with lecture notes for a class for families with a member with schizophrenia. Includes information about the illness, medication and psychosocial treatments and the role of the family in promoting recovery.
Amenson, C., Schizophrenia: Family Education Methods, Pacific Clinics, 1998.
Companion handbook to Schizophrenia: A Family Education Curriculum provides methods for forming a class, optimizing the learning of families, and dealing with typical problems that arise in conducting family classes.
Mueser K, Glynn S: Behavioral Family Therapy for Psychiatric Disorders. Oakland, New Harbinger Publications, 1999
A comprehensive model of single-Family Psychoeducation that includes a multifamily discussion/support group. The book contains individual educational handouts for various psychiatric diagnoses and handout for various related topic areas.
Psychopharmacology
The Essential Guide to Psychiatric Drugs by J. Gorman, St. Martin’s Press, 1995.
Written for a sophisticated consumer, it is the most accessible source of information about psychotropic medications. It distills the Physician’s Desk Reference into understandable language. It describes the individual “trees” (such as Prozac) in the forest of medicines. “The benzodiazepines: Are they really dangerous?” is a typical section heading.
Medicine and Mental Illness by M. Lickey and B. Gordon, Freeman, 1991.
A scholarly yet readable work written for professionals, it is best at teaching the principles of diagnosis, neurophysiology and psychopharmacological treatment of mental illness. It describes the “forest” of psychopharmacology, why it is there and how it works. “The blockade of dopamine receptors and antipsychotic potency” is a typical section heading. It does not discuss the profiles of individual medications.
Cultural Competence
The Cross-Cultural Practice of Clinical Case Management in Mental Health edited by Peter Manoleas, Haworth Press, 1996.
A collection of useful articles about the role of gender, ethnicity, and acculturation in treatment seeking and response. Provides guidelines for engaging and intervening with specific ethnic and diagnostic groups in varying treatment contexts.
Videotapes
Schizophrenia Explained by William R. McFarlane, M.D. Produced by, and order from, the author at Maine Medical Center, 22 Bramhall Street, Portland, ME 04102. (Phone 207-871-2091). mcfarw@mmc.org
This provides a full review in lay language of the psychobiology of schizophrenia, emphasizing the key concepts in Family Psychoeducation: stress reduction, optimal environments and interactions for recovery, and support for the family’s ability to contribute to recovery in many ways. It is often used in lieu of a psychiatrist during Family Education Workshops and for staffs of case management programs, community residences and employment programs to help them understand how to assist consumers with this disorder.
Exploring Schizophrenia by Christopher S. Amenson, Ph.D. Produced by the California Alliance for the Mentally Ill (Phone 916-567-0163).
This videotape uses everyday language to describe schizophrenia and give guidelines for coping with illness for consumers and their families.
Surviving and Thriving with a Mentally Ill Relative by Christopher Amenson, Ph.D., Third edition 1998.
Eighteen hours of good “home video quality” videotapes cover schizophrenia, bipolar disorder, major depressive disorder, medication, psychosocial rehabilitation, relapse prevention, motivation, and family skills. Order from Paul Burk, 1352 Hidden Springs Lane, Glendora, CA 91740. (Phone 626-335-1307).
Critical Connections: A Schizophrenia Awareness Video produced by the American Psychiatric Association, 1997.
This 30 minute video was designed by the APA to help consumers and families cope with the disabling effects of schizophrenia. It provides a hopeful, reassuring message about new medications and psychosocial treatments that assist with recovery.
Exploring Bipolar Disorder by Jerome V. Vaccaro, M.D., 1996
One hour professional quality videotape describes the illness, recovery, and the role of the family. Persons with the illness contribute valuable insights. Produced by and ordered from the California Alliance for the Mentally Ill, 1111 Howe Avenue, Suite 475, Sacramento, CA 95825. Phone 916-567-0163.
Periodicals
Schizophrenia Bulletin
Highly technical and difficult to read but it is the ultimate source for research findings. The fall 1995 issue summarizes “Treatment Outcomes Research”.
Psychiatric Services
Practical articles in all aspects of mental illness. Brief clinically relevant articles on medication and other treatments. The most useful periodical for clinical staff.
Psychosocial Rehabilitation
Practical psychosocial rehabilitation articles. Easy to read and understand. Provides “how to” details. Contains good consumer written articles.
Other Resources
There are a number of excellent books written for persons with a mental illness and their families to help them understand and deal with these illnesses. Many of these are helpful for professionals directly and all are important resources to which to refer patients and families. (See Reading List for Families.) Many of the professional and family books are offered at a discount by The National Alliance on Mental Illness, 200 N. Glebe Road, Suite 1015, Arlington, VA 22203-3754. Phone 703-524-7600.
Books on Mood Disorders (Bipolar and Unipolar Depressions)
A Brilliant Madness: Living with Manic Depressive Illness by Patty Duke and Gloria Hochman. (Bantam, 1992)
Combines personal experience with clinical information to describe manic depression in understandable terms and provide guidelines for coping with it.
Control Your Depression by Peter Lewinsohn, Ricardo Munoz, Mary Ann Youngren, and Antonette Zeiss.(Prentice Hall, Englewood Cliffs, New Jersey, 1979)
Self-help book which assesses contributors to depression and includes activities, relaxation techniques, thinking, social skills, self-control, and specific ideas and exercises for each problem area.
The Depression Workbook by Mary Ellen Copeland. (Harbinger, 1992)
Assists individuals in taking responsibility for wellness by using charts and techniques to track and control moods. The most complete and useful self help book for bipolar and unipolar depressions.
The Feeling Good Handbook by David Burns, (Penguin, New York, NY, 1989)
Self-help book presents rationale for cognitive therapy for depression. Gives specific ideas and exercises to help change thought patterns associated with depression and other problems.
Lithium and Manic Depression: A Guide by John Bohn and James Jefferson.
A very helpful guide for people with manic depression and their families regarding lithium treatment. Order from Lithium Information Center, Department of Psychiatry, University of Wisconsin, 600 Highland Ave., Madison, WI 53792.
Our Special Mom and Our Special Dad by Tootsie Sobkiewicz (Pittsburgh: Children of Mentally Ill Parents, 1994 and 1996)
Two interactive storybooks that allow primary school age children to understand and identify with the problems associated with having a mentally ill parent. Can be well utilized by a relative or therapist in individual or group work.
Overcoming Depression, Third Edition by D. & J. Papolos (Harper & Row, 1997).
A comprehensive book written for persons suffering from manic depression and major depression, as well as their families. It is the best source of information about these disorders. Does not offer coping strategies. This book and The Depression Workbook are the best two to read.
An Unquiet Mind by Kay Redfield Jamison
A compelling and emotional account of the author’s awareness, denial, and acceptance of her bipolar disorder. It offers hope and insight regarding recovery for anyone who reads it.
Books on Dual Diagnosis (Mental Illness and Substance Abuse)
Alcohol, Street Drugs, and Emotional Problems: What you need to know by B. Pepper and H. Ryglewicz.
These informative pamphlets come in versions for the client, for the family and for professionals. They can be ordered from TIE Lines, 20 Squadron Blvd. Suite 400, New York, NY 10956.
Lives at Risk: Understanding and Treating Young People with Dual Disorders by B. Pepper and H. Rygelwicz
Poignant description of the combination of schizophrenia, mood disorders, and/or personality disorders with substance abuse. Strong on empathy and understanding of the multiple problems. Provides little specific guidance.
Hazelden Publications (RW9 P.O. Box 176, Center City, MN 55012-0176 Phone 1-800-328-9000 or Website www.htbookplace.org
Publishes a large number of pamphlets and self-help books on substance abuse and dual diagnoses. Examples of titles include:
Preventing Relapse Workbook
Taking Care of Yourself: When a family member has a dual diagnosis
Twelve Steps and Dual Disorders
Understanding Schizophrenia and Addiction
Books About Children Who Have a Mental Illness
Children and Adolescents with Mental Illness: A Parents Guide by E. McElroy (Woodbine House, 1988)
Useful guide written by a psychologist who heads the NAMI Children’s and Adolescent network.
Educational Rights of Children with Disorders: A Primer for Advocates by Center for Law and Education. (Cambridge 1991.)
Neurobiological Disorders in Children and Adolescents by E. Peschel, R. Peschel and C. Howe. (Oxford Press, 1992)
Biological mental illnesses among children are less common and less understood “family problems”. This book helps to define childhood neurobiological disorders and gives guidance for finding appropriate treatment.
Books on Special Topics
Planning for the Future and the Life Planning Workbook by L. Mark Russell and Arnold Grant (American Publishing Company, 1995)
This book and accompanying workbook are guides for parents seeking to provide for the future security and happiness of an adult child with a disability following the parents’ deaths.
A Parent’s Guide to Wills and Trusts by Don Silver. (Adams-Hall, 1992)
Information on how to protect a disabled child’s financial future, written by an attorney and NAMI member.
Schizophrenia and Genetic Risks by Irving Gottesman.
This pamphlet contains detailed information about this single topic. It may be ordered from NAMI.
A Street is Not a Home: Solving American’s Homeless Dilemma by Robert Coates. (Prometheus, 1990)
Analysis and guide to dealing with homelessness among persons suffering from mental illness.
Suicide Survivors: A Guide for Those Left Behind by Adina Wrobleski. (Afterwards, 1991.)
With an understanding attitude, the author explores and offers coping suggestions for the many issues that confront families who have had a member kill himself.
Reading List For Families With A Member Who Has A Mental Illness
(Annotations by Christopher S. Amenson, Ph.D.)
Books Which Offer Guidance To Families
Coping with Schizophrenia: A Guide for Families by Kim Mueser and Susan Gingerich. (New Harbinger, 1994)
Comprehensive guide to living with schizophrenia and the best source for practical advice on topics including medication, preventing relapse, communication, family rules, drug use, and planning for the future. Includes forms and worksheets for solving typical problems.
Schizophrenia: Straight Talk for Families and Friends by Maryellen Walsh. (Morrow & Co., 1985).
A parent who, as a professional writer, thoroughly researched the field writes this book. This book is emotional in ways that will touch you and deals with all the issues important to families of persons of schizophrenia. If you can read only one book, select this one if you want to feel understood; select Understanding Schizophrenia to access current research on causes and treatments; select Coping with Schizophrenia if you want concrete advice about coping with the illness.
Surviving Schizophrenia: A Family Manual, Third Edition by E. Fuller Torrey. (Harper & Row, 1995).
Beloved by the Alliance for the Mentally Ill because it was the first book in 1983 to support and educate families. Contains one of the best descriptions of “The Inner World of Madness”. Discusses the major topics in easy to read and very pro-family language.
Troubled Journey: Coming to Terms with the Mental Illness of a Sibling or Parent by Diane Marsh and Rex Dickens (Tarcher/Putnam, 1997)
The best book for siblings and adult children. Helps to recognize and resolve the impact of mental illness on childhood. Seeks to renew self-esteem and improve current family and other relationships.
Understanding Schizophrenia: A Guide to the New Research on Causes and Treatment by Richard Keefe and Philip Harvey. (The Free Press, 1994)
The best description of research on schizophrenia as of 1994. It provides more depth and detail than Surviving Schizophrenia and is a little more difficult to read. A must for families that want to understand the science of schizophrenia.
How to Live with a Mentally Ill Person: A Handbook of Day-to-Day Strategies by Christine Adamec. (John Wiley and Sons, 1996)
This comprehensive, easy-to-read book is written by a parent. It reviews methods for accepting the illness, dealing with life issues, developing coping strategies, negotiating the mental health system, and more.
Books Describing The Experience of Schizophrenia
Anguished Voices: Siblings and Adult Children of Persons with Psychiatric Disabilities by Rex Dickens and Diane Marsh (Center for Psychiatric Rehabilitation, 1994.)
Collection of 8 well-written articles which describe the impact of mental illness on siblings and children. A poignant statement of the issues across the life span that need to be addressed when a person grows up with mental illness in the family.
Crazy Quilt by Jocelyn Riley (William Morrow, 1984)
Fictional account of a 13-year-old girl whose mother has schizophrenia. Written for children and adolescents. Provides understanding for these forgotten victims.
Is There No Place on Earth for Me? by Susan Sheehan. (Houghton-Mifflin, 1982.)
A very realistic depiction of the experience of schizophrenic woman is interwoven with information about legal, funding, and treatment issues. Gives a good description of historical and political influences on the treatment of persons suffering from schizophrenia. Won the Pulitzer Prize.
Tell Me I’m Here: One Family’s Experience with Schizophrenia by Ann Devesch. (Penquin, 1992)
Written by a United Nations Media Peace Prize winner and founder of Schizophrenia Australia, this book describes their family’s experience.
The Quiet Room by Lori Schiller. (1994)
The life story of a person who had an almost full recovery from schizophrenia with clozapine. Great for its inspirational value.
The Skipping Stone: Ripple Effects of Mental Illness on the Family by Mona Wasow (Science and Behavior Books, 1995)
Describes the impact of mental illness on each member of the family in a “Tower of Babel”. Information is from in-depth interviews with family members and professionals.
The Girl with the Crazy Brother by Betty Hyland (Franklin Watts, 1986)
Written for adolescents by an Alliance for the Mentally Ill member. Describes in short novel form the experience of a teenage girl trying to understand the sudden deterioration of her older brother.
Website resources
April 20, 2010
Bipolar Disorder In Children: Why Are The Rates Rising?
Bipolar Disorder In Children: Why Are The Rates Rising?
By Michael F. Hogan, PhD, Commissioner, New York State Office of Mental Health; and
Lloyd I. Sederer, M.D., Medical Director, New York State Office of Mental Health
Recent media reports tell us that the diagnosis of bipolar disorder in children and adolescents (formerly called manic depressive disorder) is forty times more frequent than it was just ten years ago. Can the numbers of children and adolescents with this illness increase so rapidly? Are medications being over-prescribed?
The rapid increase in diagnoses in such a short period of time cannot be explained by changes in genetics, environment or families. In part it must be due to a broader definition of the illness, which now includes anger and hyperactivity.
But the signs and symptoms needed to make the diagnosis of bipolar disorder, according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM IV) have not changed in recent years. Diagnoses are being made more liberally, perhaps to the benefit of some children but clearly also to the detriment of others.
For a reliable diagnosis to be made, symptoms common in this disorder such as mood swings, irritability and impulsive behavior must occur during a distinct period of a mood disturbance, a hallmark of this illness and the DSM IV definition. Many children are impulsive and irritable, but that in itself does not meet the criteria for this illness. These symptoms occur with other disorders found in children and adolescents, such as attention deficit hyperactivity disorder (ADHD), depression with agitation and irritability, conduct disorder, and substance use disorders.
A diagnosis of bipolar disorder in children and adolescents does not tell us if the childhood form of the illness will continue into adulthood. Many children with mood swings, depression, and irritability have been brought to physicians over many years. They have been diagnosed with various disorders, including ADHD, conduct disorder and depression, according to the trends at the time. Diagnoses made today may change for individual children as they age, and for children in the future as psychiatry matures.
What should psychiatrists do now? What should parents and caretakers expect in the treatment of their children? A heightened awareness of the existence of bipolar disorder in children may be beneficial if it helps us to recognize more cases of true bipolar disorder and institute treatment earlier. It can also cause confusion and concern in parents and psychiatrists around the use of the medications prescribed for bipolar disorder.
First, a child should be assessed directly by a child and adolescent psychiatrist with information obtained from parents, caregivers and sometimes teachers. Second, valid rating scales can help introduce some objectivity to what is still a professional judgement. The Mood Disorder Questionnaire and the Young Mania Rating Scale are specific to bipolar disorder. Scales such as the Conners’ (with parent and teacher rating forms) for hyperactivity and ADHD can help to differentiate these common conditions, even if many children and adolescents with bipolar disorder also have ADHD. The Beck Depression Inventory (children’s version) can help identify depression. Third, as noted earlier, a consultation or second opinion is another important way to confirm or refute a diagnosis made by one doctor. This is especially valuable in children whose behaviors stimulate desperate efforts to “do something.” Any doctor not open to a second opinion should be suspect.
The treatment of bipolar disorder in children and adolescents, or any mental disorder for that matter, begins with forming a trusting relationship with the child and parents. This means the physician should provide information and educate the family about mental illness, be open to questions and concerns, and share decision-making. Benefits, risks and side-effects of any treatment must be offered in a clear and understandable manner; if you as a parent or youth do not understand, say so and expect a good answer.
Medications are a primary treatment for bipolar disorder and many mental illnesses, and they can provide invaluable help. But medications are only one form of intervention, and not enough in themselves. Various forms of psychotherapy in association with medication may be helpful. In particular, “psycho-educational treatment” for the child and parents provides concrete information about the illness, its impact, and treatment options. Cognitive behavior therapy can be especially helpful in the depressive phase of bipolar disorder and is effective in reducing disruptive behaviors. Support groups for families of children and adolescents with bipolar disorder and other severe disorders also can be helpful.
In light of the rise in diagnosis of this disorder, doctors, families and youth have reason to be concerned that a diagnosis is accurate and the treatment it leads to is optimal. Families should insist on clear information, seek second opinions when unsure, and demand monitoring of care to see if the diagnosis “holds” over time. Parents and youth should expect careful observation of any prescribed medications, and recognize that medications may be a critical part of the treatment but they are not sufficient when it comes to the care of our children.
By Michael F. Hogan, PhD, Commissioner, New York State Office of Mental Health; and
Lloyd I. Sederer, M.D., Medical Director, New York State Office of Mental Health
Recent media reports tell us that the diagnosis of bipolar disorder in children and adolescents (formerly called manic depressive disorder) is forty times more frequent than it was just ten years ago. Can the numbers of children and adolescents with this illness increase so rapidly? Are medications being over-prescribed?
The rapid increase in diagnoses in such a short period of time cannot be explained by changes in genetics, environment or families. In part it must be due to a broader definition of the illness, which now includes anger and hyperactivity.
But the signs and symptoms needed to make the diagnosis of bipolar disorder, according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM IV) have not changed in recent years. Diagnoses are being made more liberally, perhaps to the benefit of some children but clearly also to the detriment of others.
For a reliable diagnosis to be made, symptoms common in this disorder such as mood swings, irritability and impulsive behavior must occur during a distinct period of a mood disturbance, a hallmark of this illness and the DSM IV definition. Many children are impulsive and irritable, but that in itself does not meet the criteria for this illness. These symptoms occur with other disorders found in children and adolescents, such as attention deficit hyperactivity disorder (ADHD), depression with agitation and irritability, conduct disorder, and substance use disorders.
A diagnosis of bipolar disorder in children and adolescents does not tell us if the childhood form of the illness will continue into adulthood. Many children with mood swings, depression, and irritability have been brought to physicians over many years. They have been diagnosed with various disorders, including ADHD, conduct disorder and depression, according to the trends at the time. Diagnoses made today may change for individual children as they age, and for children in the future as psychiatry matures.
What should psychiatrists do now? What should parents and caretakers expect in the treatment of their children? A heightened awareness of the existence of bipolar disorder in children may be beneficial if it helps us to recognize more cases of true bipolar disorder and institute treatment earlier. It can also cause confusion and concern in parents and psychiatrists around the use of the medications prescribed for bipolar disorder.
First, a child should be assessed directly by a child and adolescent psychiatrist with information obtained from parents, caregivers and sometimes teachers. Second, valid rating scales can help introduce some objectivity to what is still a professional judgement. The Mood Disorder Questionnaire and the Young Mania Rating Scale are specific to bipolar disorder. Scales such as the Conners’ (with parent and teacher rating forms) for hyperactivity and ADHD can help to differentiate these common conditions, even if many children and adolescents with bipolar disorder also have ADHD. The Beck Depression Inventory (children’s version) can help identify depression. Third, as noted earlier, a consultation or second opinion is another important way to confirm or refute a diagnosis made by one doctor. This is especially valuable in children whose behaviors stimulate desperate efforts to “do something.” Any doctor not open to a second opinion should be suspect.
The treatment of bipolar disorder in children and adolescents, or any mental disorder for that matter, begins with forming a trusting relationship with the child and parents. This means the physician should provide information and educate the family about mental illness, be open to questions and concerns, and share decision-making. Benefits, risks and side-effects of any treatment must be offered in a clear and understandable manner; if you as a parent or youth do not understand, say so and expect a good answer.
Medications are a primary treatment for bipolar disorder and many mental illnesses, and they can provide invaluable help. But medications are only one form of intervention, and not enough in themselves. Various forms of psychotherapy in association with medication may be helpful. In particular, “psycho-educational treatment” for the child and parents provides concrete information about the illness, its impact, and treatment options. Cognitive behavior therapy can be especially helpful in the depressive phase of bipolar disorder and is effective in reducing disruptive behaviors. Support groups for families of children and adolescents with bipolar disorder and other severe disorders also can be helpful.
In light of the rise in diagnosis of this disorder, doctors, families and youth have reason to be concerned that a diagnosis is accurate and the treatment it leads to is optimal. Families should insist on clear information, seek second opinions when unsure, and demand monitoring of care to see if the diagnosis “holds” over time. Parents and youth should expect careful observation of any prescribed medications, and recognize that medications may be a critical part of the treatment but they are not sufficient when it comes to the care of our children.
April 19, 2010
Disaster Reactions of Potential Risk Groups
Training Manual
for Mental Health and Human Service Workers
in Major Disasters
SECTION 3
Disaster Reactions of Potential Risk Groups
Although there are many feelings and reactions people share in common following a disaster, there are also expressions that are more specifically influenced by the survivor's age, cultural and ethnic background, socioeconomic status, pre-existing physical, and psychosocial vulnerabilities. Disaster mental health workers are better prepared to design effective interventions when they have an understanding of how demographic and health factors interact with disaster stress.
This section describes groups commonly found within communities following a disaster and provides suggestions for disaster mental health interventions. Common issues, concerns, and reactions are also briefly presented in this section.
Common Needs and Reactions
First is a review of some thoughts, feelings, and behaviors common to all who experience a disaster:
Concern for basic survival
Grief over loss of loved ones and loss of valued and meaningful possessions
Fear and anxiety about personal safety and the physical safety of loved ones
Sleep disturbances, often including nightmares and imagery from the disaster
Concerns about relocation and related isolation or crowded living conditions
Need to talk about events and feelings associated with the disaster, often repeatedly
Need to feel one is a part of the community and its disaster recovery efforts
Potential Risk Groups
Each disaster-affected community has its own demographic composition, prior history with disasters or other traumatic events, and cultural representation. When disaster program planners review the groups impacted by a disaster in their community, consideration should be given to the following, as well as additional groups unique to the locale:
Age groups
Cultural and ethnic groups
Socioeconomic groups
People with serious and persistent mental illness
Human service and disaster relief workers
The majority of survivors are resilient and with time can integrate their disaster experiences and losses and move on. However, survivors who have significant concurrent psychosocial, health, or financial problems are at greater risk for depression, anxiety, post-traumatic stress symptoms or an exacerbation of their pre-existing condition. When survivors have personally sustained severe disaster losses (e.g., death of a loved one, devastation of home and community), their reactions are more intensely expressed and over a longer period of time (Solomon & Green, 1992). This section includes a brief overview for each group. The disaster reactions described normally resolve over time with sufficient support and physical recovery. References for more detailed information are provided.
Age Groups
Each stage of life is accompanied by special challenges in coping with the aftermath of a disaster and age-related vulnerabilities to disaster stress. For children, their age and development determine their capacity cognitively to understand what is occurring around them and to regulate their emotional reactions. Children are more vulnerable to difficulty when they have experienced other life stresses in the year preceding the disaster, such as a divorce, a move, or the death of a family member or pet (Vogel & Vernberg, 1993). For adults, stress associated with family and home disruption, financial setbacks, and work overload predominate. For older adults, concerns regarding health, financial stability, and living independently become primary.
The age groups considered in this section are:
Preschool (ages 1-5)
Childhood (ages 6-11)
Pre-adolescence and Adolescence (ages 12-18)
Adults
Older Adults
Reactions and problems vary depending upon the phase of the post-disaster period. Some of the problems discussed appear immediately; many appear months later.
Preschool (ages 1-5)
Small children view their world from the perspectives of predictability, stability, and the availability of dependable caretakers. Disruption in any of these domains causes distress. Preschool age children often feel powerlessness and fear in the face of a disaster, especially if they are separated from parents. Because of their age and small size, they are unable to protect themselves or others. As a result, they may feel considerable anxiety and insecurity.
In the preschool years, children generally lack the verbal and conceptual skills necessary to understand and cope effectively with sudden unexpected stress. They typically look to parents and older siblings as behavior models, as well as for comfort and stability. Research has shown that children's reactions are more related to how their family or caregiver is coping than the actual objective characteristics of the disaster itself (Green et al., 1991).
Children who have lost one or both parents are especially in need. Loss of a relative, a playmate, or a pet is also a disturbing event for children. They will need opportunities to express their grief. One of the major fears of childhood is abandonment, so children need frequent reassurance they will be cared for.
Preschoolers express their upset through regressive behaviors such as thumb sucking, bed-wetting, clinging to their parents, a return of fear of the dark, or not wanting to sleep alone. They often have sleep problems and frightening dreams. These problems are best understood as normal expressions of anxiety about the disruption of their familiar routines and previously secure worlds.
In the natural course of events, small children will try to resolve traumatic experiences by reliving them in their play activities. They may reenact the earthquake, flood, or tornado repeatedly. Children should be encouraged to verbalize their questions, feelings, and misunderstandings about the disaster so that adults can listen and explain. Relief of disaster fears and anxiety is attained through reestablishing the child's sense of security. Frequent verbal reassurance, physical comforting, more frequent attention, comforting bedtime rituals, and mealtime routines are helpful. As much as possible, young children should stay with people with whom they feel most familiar.
Childhood (ages 6 - 11)
School age children are developing the cognitive capacity to understand the dangers to family and environment inherent in disasters. They are more able to understand the disaster event and the mitigating role of disaster preparedness. This awareness can also contribute to preoccupation with weather and disasters, and fears about family members being killed or injured. School age children have a great need to understand what has happened and the concrete steps that they can take for protection and preparedness in the future.
Children often have special bonds with playmates or pets. When the disaster causes loss of significant others due to death or relocation, the child may grieve deeply. They experience the full range of human emotions, but may not have the words or means to express their internal experience. Adults can assist children to express these powerful emotions through talking, play, art, and age-appropriate recovery or preparedness activities.
School age children also manifest their anxiety through regressive behavior. Returning to behavior appropriate for a younger age is trying for parents, but serves an initially functional purpose for the child. These behaviors include: irritability, whining, clinging, fighting with friends and siblings, competing with younger siblings for parents' attention, or refusing to go to school. Bedtime and sleep problems are common due to nightmares and fearfulness about sleeping alone or in the dark.
Sometimes children's behavior can be "super good" at home, because they are afraid of further burdening their parents or causing more family disruption. They may show disaster stress at school through concentration problems, a decline in academic performance, aggression toward classmates, or withdrawal from social interactions. Some children may have somatic reactions and seek attention from the school nurse for stomach aches, headaches, nausea, or other complaints.
Pre-adolescence and Adolescence (ages 12 - 18)
This age group has a great need to appear competent to the world around them, especially to their family and friends. They struggle with the conflicts inherent in moving toward independence from parents on the one hand and the desire to maintain the dependence of childhood on the other. Approval and acceptance from friends are of paramount importance. Adolescents need to feel that their anxieties and fears are both appropriate and shared by their peers.
Disaster stress may be internalized and expressed through psychosomatic symptoms such as, gastrointestinal distress, headaches, skin problems, or vague aches and pains. Sleep problems such as insomnia, night terrors, or sleeping excessively may signal internal upset. Adolescents may turn to alcohol or drugs to cope with their anxiety and loss.
Social or school problems may also occur. Acting out or rebellious behavior may involve fighting with others, stealing, or power struggles with parents. Other adolescents may express their distress through withdrawal from friends and family and avoidance of previously enjoyed activities. School performance may decline. When the disaster causes major destruction of home and community, an older adolescent may postpone the developmental step of moving away from home.
Adults
Adults are focused on family, home, jobs, and financial security. Many are involved with caring for elderly parents as well. Pre-disaster life often involves maintaining a precarious balance between competing demands. Following a disaster, this balance is lost with the introduction of the enormous time, financial, physical, and emotional demands of recovery. Children in the family are in special need of attention and familiar routines, yet parents do not have enough hours in the day to accomplish all that is before them.
Over time, this stress overload can be manifested through physical symptoms of headaches, increased blood pressure, ulcers, gastrointestinal problems, and sleep disorders. Somatic reactions are especially present in those who are less able to experience and express their emotions directly. Cultural, gender-based, or psychological factors may interfere with emotional expression and seeking social support.
Emotional reactions often oscillate between numbness and intense expression. Anxiety and depression are common, as adults grapple with both anxiety about future threats and grief about the loss of home, lifestyle, or community. Anger and frustration about relief efforts abound, sometimes reflecting a displacement of the "less rational" anger that the disaster happened to them and was out of their control.
Older Adults
In the normal course of life, older adults typically have coped with losses prior to the disaster. They may have successfully adjusted to losses of employment, family, home, loved ones, or physical capabilities. For some, coping with these prior losses has strengthened resilience. For others, the prior losses may have worn down the individual's reserves and the disaster is an overwhelming blow (Norris et al., 1994). As a result of the disaster, irreplaceable possessions such as photographs or mementos passed on through generations may be destroyed. Pets or gardens developed over years may be lost. Mental health workers must recognize the special meaning of these losses, if they are to assist with grieving.
Older adults living on limited incomes tend to reside in dwellings that are susceptible to disaster hazards due to the location and age of the buildings. Because of financial limitations and age, they may not be able to afford the repairs to their homes. Leaving familiar surroundings is especially difficult for those who experience deficits in hearing, vision, or memory, because they rely on known environmental cues to continue living independently.
Many older adults fear that if their diminished physical or cognitive abilities are revealed, they risk loss of independence or being institutionalized. As a result, they may under report the full extent of their problems and needs. They may continue living in damaged or unsanitary conditions, because they do not have the physical strength, stamina, or cognitive organizational ability to undertake disaster clean up. Disaster mental health workers must carefully assess the range and full extent of problems in living faced by the older survivor. Often, concrete practical assistance for recovery, stabilization, and engagement with appropriate resources allows the older adult to continue living independently.
A larger proportion of older persons, as compared with younger age groups, have chronic illnesses that may worsen with the stress of a disaster, particularly when recovery extends over months. They are more likely to be taking medications that need to be replaced quickly following a disaster. While older adults may be in more need of multiple services for recovery, they are often especially reluctant to accept help and what they perceive as "handouts." Disaster mental health programs can more quickly gain acceptance when they work closely with known, trusted organizations and employ older adults as outreach workers.
Disaster Reactions and Intervention Suggestions
Age Groups
Behavioral Symptoms
Physical Symptoms
Emotional Symptoms
Intervention Options
PRESCHOOL
(1 - 5)
Resumption of bed-wetting, thumb sucking
Clinging to parents
Fears of the dark
Avoidance of sleeping alone
Increased crying
Loss of appetite
Stomach aches
Nausea
Sleep problems, nightmares
Speech difficulties
Tics
Anxiety
Fear
Irritability
Angry outbursts
Sadness
Withdrawal
Give verbal assurance and physical comfort
Provide comforting bedtime routines
Avoid unnecessary separations
Permit child to sleep in parents' room temporarily
Encourage expression regarding losses (i.e., deaths, pets, toys)
Monitor media exposure to disaster trauma
Encourage expression through play activities
CHILDHOOD
(6 - 11)
Decline in school performance
Aggressive behavior at home or school
Hyperactive or silly behavior
Whining, clinging, acting like a younger child
Increased competition with younger siblings for parents' attention
Change in appetite
Headaches
Stomach aches
Sleep disturbances, nightmares
School avoidance
Withdrawal from friends, familiar activities
Angry outbursts
Obsessive preoccupation with disaster, safety
Give additional attention and consideration
Relax expectations of performance at home and at school temporarily
Set gentle but firm limits for acting out behavior
Provide structured but undemanding home chores and rehabilitation activities
Encourage verbal and play expression of thoughts and feelings
Listen to the child's repeated retelling of disaster event
Involve the child in preparation of family emergency kit, home drills
Rehearse safety measures for future disasters
Develop school disaster program for peer support, expressive activities, education on disasters, preparedness planning, identifying at-risk children
Disaster Reactions and Intervention Suggestions (Continued)
Age Groups
Behavioral Symptoms
Physical Symptoms
Emotional Symptoms
Emotional Symptoms
PRE-ADOLESCENCE AND ADOLESCENCE
(12 - 18)
Decline in academic performance
Rebellion at home or school
Decline in previous responsible behavior
Agitation or decrease in energy level, apathy
Delinquent behavior
Social withdrawal
Appetite changes
Headaches
Gastrointestinal problems
Skin eruptions
Complaints of vague aches and pains
Sleep disorders
Loss of interest in peer social activities, hobbies, recreation
Sadness or depression
Resistance to authority
Feelings of inadequacy and helplessness
Give additional attention and consideration
Relax expectations of performance at home and school temporarily
Encourage discussion of disaster experiences with peers, significant adults
Avoid insistence on discussion of feelings with parents
Encourage physical activities
Rehearse family safety measures for future disasters
Encourage resumption of social activities, athletics, clubs, etc.
Encourage participation in community rehabilitation and reclamation work
Develop school programs for peer support and debriefing, preparedness planning, volunteer community recovery, identifying at-risk teens
ADULTS
Sleep problems
Avoidance of reminders
Excessive activity level
Crying easily
Increased conflicts with family
Hypervigilance
Isolation, withdrawal
Fatigue, exhaustion
Gastrointestinal distress
Appetite change
Somatic complaints
Worsening of chronic conditions
Depression, sadness
Irritability, anger
Anxiety, fear
Despair, hopelessness
Guilt, self doubt
Mood swings
Provide supportive listening and opportunity to talk in detail about disaster experiences
Assist with prioritizing and problem-solving
Offer assistance for family members to facilitate communication and effective functioning
Assess and refer when indicated
Provide information on disaster stress and coping, children's reactions and families
Provide information on referral resources
Disaster Reactions and Intervention Suggestions (Continued)
Age Groups
Behavioral Symptoms
Physical Symptoms
Emotional Symptoms
Intervention Options
OLDER ADULTS
Withdrawal and isolation
Reluctance to leave home
Mobility limitations
Relocation adjustment problems
Worsening of chronic illnesses
Sleep disorders
Memory problems
Somatic symptoms
More susceptible to hypo- and hyperthermia
Physical and sensory limitations (sight, hearing) interfere with recovery
Depression
Despair about losses
Apathy
Confusion, disorientation
Suspicion
Agitation, anger
Fears of institutionalization
Anxiety with unfamiliar surroundings
Embarrassment about receiving "hand outs"
Provide strong and persistent verbal reassurance
Provide orienting information
Use multiple assessment methods as problems may be under reported (e.g., repeat observations, geriatric screening questions, discussion with family)
Provide assistance with recovery of possessions
Assist in obtaining medical and financial assistance
Assist in reestablishing familial and social contacts
Give special attention to suitable residential relocation
Encourage discussion of disaster losses and expression of emotions
Provide and facilitate referrals for disaster assistance
Engage providers of transportation, chore services, meals programs, home health, and home visits as needed
Cultural and Ethnic Groups
Disaster mental health programs must respond specifically and sensitively to the various cultural groups affected by a disaster. In many disasters, ethnic and racial minority groups may be especially hard hit because of socioeconomic conditions that force the community to live in housing that is particularly vulnerable. Language barriers, suspicion of governmental programs due to prior experiences, rejection of outside interference or assistance, and differing cultural values often contribute to disaster outreach programs' difficulty in establishing access and acceptance. Communities that take pride in their self-reliance are reluctant to seek or accept help, especially from mental health workers.
Cultural sensitivity is conveyed when disaster information and application procedures are translated into primary spoken languages and available in non-written forms. Intense emotions are typically experienced and expressed in a person's language of origin, so outreach teams that include bilingual, bicultural staff, and translators are able to interact more effectively with disaster survivors. Whenever possible, it is preferable to work with trained translators rather than family members, especially children, because of privacy concerns regarding mental health issues and the importance of preserving family roles.
Cultural groups have considerable variation regarding views on loss, death, home, spiritual practices, use of particular words, grieving, celebrating, mental health, and helping. The role of the family, who is included in the family, and who makes decisions also varies. Elders and extended family play a significant role in some cultures, whereas isolated nuclear families are the decision-makers in others.
It is essential that disaster mental health workers learn about the cultural norms, traditions, local history, and community politics from leaders and social service workers indigenous to the groups they are serving. Program outreach workers and mental health staff are most effective when they are bilingual and bicultural. During the program development phase, establishing working relationships with trusted organizations, service providers, and community leaders is helpful. Being respectful, nonjudgmental, well informed, and following through on stated plans dependably are especially important for outreach workers.
Socioeconomic Groups
Many affluent, middle to upper middle class people live with a sense of security and see themselves as invulnerable to the devastation and tragedy associated with disasters. Because of their financial resources and life situations, they may have been protected from crises in the past, and have purchased insurance for "protection" in the future. They are more accustomed to planning and controlling life events, rather than unexpected overwhelming events controlling them. Shock, disbelief, self blame, and anger predominate in the hours and days following a major disaster, as the reality of losses, danger, and the work that lies ahead begins to sink in.
Higher income families may never have received assistance from social service agencies before. Accepting clothing, food, money, or shelter can be difficult and sobering. While they may need emergency assistance initially, they often do have social, financial, family, or other resources that engage quickly and buffer the disaster's impact.
Affluent families typically rely on known professionals for their support-their family physician, minister, or psychotherapist. Disaster mental health programs focus on educating local health care professionals and religious leaders about disaster stress, because these providers are most likely to encounter upper class survivors in need. Psychosocial Issues for Children and Families in Disaster: A Guide for the Primary Care Physician (CMHS, 1995) is an informative resource for training. Recovery programs can also coordinate disaster mental health counseling and support groups through these known and trusted entities.
In contrast, low-income survivors have fewer resources and greater pre-existing vulnerability when disaster strikes. While they may have developed more crisis survival skills than the more protected upper class individuals, they often lack the availability of support and housing from family and friends and do not have insurance coverage or monetary savings. Without these, the recovery process is even more arduous and prolonged, and sometimes impossible. Federal and State disaster assistance programs are designed to meet serious and urgent needs. The intent of these programs is not to replace all losses. Uninsured, poor families may have unmet needs and should be referred to non-profit disaster relief organizations and unmet needs committees. If they are renters, they may be faced with unaffordable increases in rent after landlords have invested money to repair their properties. They may be dislocated to temporary disaster housing that is undesirable and removed from their social supports. Relocation may make transportation and getting to appointments more difficult.
Faced with these multiple challenges and assistance that falls short of solving the problems before them, low-income disaster survivors can feel overwhelmed. For those with limited reading and writing abilities, obtaining accurate information and completing forms is difficult. Disaster mental health workers are most effective when they provide concrete problem-solving assistance that facilitates addressing priority needs. Workers must be knowledgeable about the full range of community resources available to people of limited economic means and actively engage this resource network with those in need.
People With Serious and Persistent Mental Illness
Clinical field experience has shown that disaster survivors with mental illness function fairly well following a disaster, if essential services have not been interrupted. People with mental illness have the same capacity to "rise to the occasion" and perform heroically as the general population during the immediate aftermath of the disaster. Many demonstrate an increased ability to handle this stress without an exacerbation of their mental illness, especially when they are able to maintain their medication regimens.
However, some survivors with mental illness have achieved only a tenuous balance before the disaster. The added stress of the disaster disrupts this balance; for some, additional mental health support services, medications, or hospitalization may be necessary to regain stability. For individuals diagnosed with Post Traumatic Stress Disorder (PTSD), disaster stimuli (e.g., helicopters, sirens) may trigger an exacerbation due to associations with prior traumatic events.
Many people with mental illness are vulnerable to sudden changes in their environment and routines. Orienting to new organizations and systems for disaster relief assistance can be difficult. Program planners need to be aware of how disaster services are being perceived and build bridges that facilitate access and referrals where necessary. Disaster mental health services designed for the general population are equally beneficial for those with mental illness; disaster stress affects all groups. In addition, when case managers and community mental health counselors have a solid understanding of disaster mental health issues, they are able to better provide services to this population following a disaster. Responding to the Needs of People with Serious and Persistent Mental Illness in Times of Major Disaster provides a comprehensive discussion of planning, preparedness, and options for service delivery with this population (CMHS, 1996).
Human Service and Disaster Relief Workers
Workers in all phases of disaster relief, whether in law enforcement, local government, emergency response, or victim support, experience considerable demands to meet the needs of the survivors and the community. Typically, disaster workers are altruistic, compassionate, and dedicated people who occasionally have difficulty knowing when it is time to take a break from the operation. For many, the disaster response takes precedence over all other responsibilities and activities. The brochure, Prevention and Control of Stress Among Emergency Workers-A Pamphlet for Workers, is an excellent resource for both disaster relief workers and mental health providers (NIMH, 1987). This brochure highlights the importance of having a personal emergency preparedness plan, so that workers are assured that their families are safe while they devote themselves to disaster relief for the community.
Relief workers may witness human tragedy and serious physical injuries, depending on the nature of the disaster and their role. This contributes to the psychological impact of their work. In disasters in which there is a high level of exposure to human suffering, injuries, and fatalities, providing psychological support and interventions for workers is especially necessary. In addition, relief workers and first responders should be considered a target group for ongoing services during the course of the disaster mental health recovery program.
As some order returns to the community, many workers, particularly volunteers, return to their regular jobs. However, they may attempt to continue with their disaster work. Over time, the result of this overwork can be the "burn-out" syndrome. This state of exhaustion, irritability, and fatigue creeps up unrecognized and can markedly decrease the individual's effectiveness and capability. These workers may be avoiding problems at home by working constantly. Disaster mental health workers should be on the lookout for workers whose coping resources have eroded due to their personal vulnerabilities and seemingly unrelenting workload. The next section in this manual, "Stress Prevention and Management," offers suggestions for identifying, educating, and intervening with those who may be having stress reactions and difficulty coping.
References and Recommended Reading
Bolin, R. & Bolton, P. Race, Religion and Ethnicity in Disaster Recovery. Colorado: University of Colorado Institute of Behavioral Science, 1986.
Center for Mental Health Services. Manual for Child Health Workers in Major Disasters. Washington, D.C.: U.S. Department of Health and Human Services; Publication No. (ADM) 86-1070. (Rev. ed. in press.)
Center for Mental Health Services. Responding to the Needs of People with Serious and Persistent Mental Illness in Times of Major Disaster. Washington, D.C.: U.S. Department of Health and Human Services; Publication No. (SMA) 96-3077, 1996.
Center for Mental Health Services. Psychosocial Issues for Children and Families in Disasters: A Guide for the Primary Care Physician. Washington, D.C.: US Department of Health and Human Services; Publication No. (SMA) 95-3022, 1995.
Gerrity, E. T. & Steinglass, P. Relocation stress following natural disasters. In: Ursano, R. J., McCaughey, B. G., & Fullerton, C. S. (Eds.). Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos. Great Britain: Cambridge University Press, 1994.
Gist, R. & Lubin, B. (Eds.). Psychological Aspects of Disaster. New York: John Wiley & Sons, 1989.
Green, B. L., Korol, M., Grace, M. C., Vary, M. G., Leonard, A. C., Gleser, G. C. & Smitson-Cohen, S. Children and disaster: Age, gender, and parental effects on PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 945-951, 1991.
Green, B. L. & Solomon, S. D. The mental health impact of natural and technological disasters. In Freedy, J. R. & Hobfoll (Eds.). Traumatic Stress: From Theory to Practice. New York: Plenum, 1995.
LaGreca, A. M., Vernberg, E. M., Silverman, W. K., Vogel, A. L. & Prinstein, M. J. Helping Children Prepare for and Cope with Natural Disasters: A Manual for Professionals Working with Elementary School Children. BellSouth Corporation, 1995. (To obtain copies: Contact Dr. La Greca, Department of Psychology, University of Miami, P.O. Box 248185, Coral Gables, FL 33124.)
Mitchell, J. & Bray, G. Emergency Services Stress: Guidelines for Preserving the Health and Careers of Emergency Services Personnel. New Jersey: Prentice-Hall, 1990.
National Institute of Mental Health. Prevention and Control of Stress Among Emergency Workers: A Pamphlet for Workers. Washington, D.C.: U. S. Department of Health and Human Services; Publication No. (ADM) 90-1497, 1987.
Norris, F. H., Phifer, J. F. & Kaniasty, K. Individual and community reactions to the Kentucky floods: Findings from a longitudinal study of older adults. In: Ursano, R. J., McCaughey, B. G., & Fullerton, C. S. (Eds.). Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos. Great Britain: Cambridge University Press, 1994.
Saylor, C. F. (Ed.). Children and Disasters. New York: Plenum Press, 1993.
Solomon, S. D. & Green, B. L. Mental health effects of natural and human-made disasters. PTSD Research Quarterly, 3 (1), 1-8, 1992.
Sue, D. W. & Sue, D. Counseling the Culturally Different: Theory and Practice. New York: Wiley, 1990.
Ursano, R. J., McCaughey, B. G., & Fullerton, C. S. (Eds.). Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos. Great Britain: Cambridge University Press, 1994.
U. S. Department of Health and Human Services. Action Plan of the Administration on Aging to Strengthen the Disaster Response Capacity to Serve Older People. Rockville, MD, 1994. Vogel, J. M. & Vernberg, E. M. Children's psychological responses to disasters. Journal of Clinical Child Psychology, 22(4), 464-484, 1993.
for Mental Health and Human Service Workers
in Major Disasters
SECTION 3
Disaster Reactions of Potential Risk Groups
Although there are many feelings and reactions people share in common following a disaster, there are also expressions that are more specifically influenced by the survivor's age, cultural and ethnic background, socioeconomic status, pre-existing physical, and psychosocial vulnerabilities. Disaster mental health workers are better prepared to design effective interventions when they have an understanding of how demographic and health factors interact with disaster stress.
This section describes groups commonly found within communities following a disaster and provides suggestions for disaster mental health interventions. Common issues, concerns, and reactions are also briefly presented in this section.
Common Needs and Reactions
First is a review of some thoughts, feelings, and behaviors common to all who experience a disaster:
Concern for basic survival
Grief over loss of loved ones and loss of valued and meaningful possessions
Fear and anxiety about personal safety and the physical safety of loved ones
Sleep disturbances, often including nightmares and imagery from the disaster
Concerns about relocation and related isolation or crowded living conditions
Need to talk about events and feelings associated with the disaster, often repeatedly
Need to feel one is a part of the community and its disaster recovery efforts
Potential Risk Groups
Each disaster-affected community has its own demographic composition, prior history with disasters or other traumatic events, and cultural representation. When disaster program planners review the groups impacted by a disaster in their community, consideration should be given to the following, as well as additional groups unique to the locale:
Age groups
Cultural and ethnic groups
Socioeconomic groups
People with serious and persistent mental illness
Human service and disaster relief workers
The majority of survivors are resilient and with time can integrate their disaster experiences and losses and move on. However, survivors who have significant concurrent psychosocial, health, or financial problems are at greater risk for depression, anxiety, post-traumatic stress symptoms or an exacerbation of their pre-existing condition. When survivors have personally sustained severe disaster losses (e.g., death of a loved one, devastation of home and community), their reactions are more intensely expressed and over a longer period of time (Solomon & Green, 1992). This section includes a brief overview for each group. The disaster reactions described normally resolve over time with sufficient support and physical recovery. References for more detailed information are provided.
Age Groups
Each stage of life is accompanied by special challenges in coping with the aftermath of a disaster and age-related vulnerabilities to disaster stress. For children, their age and development determine their capacity cognitively to understand what is occurring around them and to regulate their emotional reactions. Children are more vulnerable to difficulty when they have experienced other life stresses in the year preceding the disaster, such as a divorce, a move, or the death of a family member or pet (Vogel & Vernberg, 1993). For adults, stress associated with family and home disruption, financial setbacks, and work overload predominate. For older adults, concerns regarding health, financial stability, and living independently become primary.
The age groups considered in this section are:
Preschool (ages 1-5)
Childhood (ages 6-11)
Pre-adolescence and Adolescence (ages 12-18)
Adults
Older Adults
Reactions and problems vary depending upon the phase of the post-disaster period. Some of the problems discussed appear immediately; many appear months later.
Preschool (ages 1-5)
Small children view their world from the perspectives of predictability, stability, and the availability of dependable caretakers. Disruption in any of these domains causes distress. Preschool age children often feel powerlessness and fear in the face of a disaster, especially if they are separated from parents. Because of their age and small size, they are unable to protect themselves or others. As a result, they may feel considerable anxiety and insecurity.
In the preschool years, children generally lack the verbal and conceptual skills necessary to understand and cope effectively with sudden unexpected stress. They typically look to parents and older siblings as behavior models, as well as for comfort and stability. Research has shown that children's reactions are more related to how their family or caregiver is coping than the actual objective characteristics of the disaster itself (Green et al., 1991).
Children who have lost one or both parents are especially in need. Loss of a relative, a playmate, or a pet is also a disturbing event for children. They will need opportunities to express their grief. One of the major fears of childhood is abandonment, so children need frequent reassurance they will be cared for.
Preschoolers express their upset through regressive behaviors such as thumb sucking, bed-wetting, clinging to their parents, a return of fear of the dark, or not wanting to sleep alone. They often have sleep problems and frightening dreams. These problems are best understood as normal expressions of anxiety about the disruption of their familiar routines and previously secure worlds.
In the natural course of events, small children will try to resolve traumatic experiences by reliving them in their play activities. They may reenact the earthquake, flood, or tornado repeatedly. Children should be encouraged to verbalize their questions, feelings, and misunderstandings about the disaster so that adults can listen and explain. Relief of disaster fears and anxiety is attained through reestablishing the child's sense of security. Frequent verbal reassurance, physical comforting, more frequent attention, comforting bedtime rituals, and mealtime routines are helpful. As much as possible, young children should stay with people with whom they feel most familiar.
Childhood (ages 6 - 11)
School age children are developing the cognitive capacity to understand the dangers to family and environment inherent in disasters. They are more able to understand the disaster event and the mitigating role of disaster preparedness. This awareness can also contribute to preoccupation with weather and disasters, and fears about family members being killed or injured. School age children have a great need to understand what has happened and the concrete steps that they can take for protection and preparedness in the future.
Children often have special bonds with playmates or pets. When the disaster causes loss of significant others due to death or relocation, the child may grieve deeply. They experience the full range of human emotions, but may not have the words or means to express their internal experience. Adults can assist children to express these powerful emotions through talking, play, art, and age-appropriate recovery or preparedness activities.
School age children also manifest their anxiety through regressive behavior. Returning to behavior appropriate for a younger age is trying for parents, but serves an initially functional purpose for the child. These behaviors include: irritability, whining, clinging, fighting with friends and siblings, competing with younger siblings for parents' attention, or refusing to go to school. Bedtime and sleep problems are common due to nightmares and fearfulness about sleeping alone or in the dark.
Sometimes children's behavior can be "super good" at home, because they are afraid of further burdening their parents or causing more family disruption. They may show disaster stress at school through concentration problems, a decline in academic performance, aggression toward classmates, or withdrawal from social interactions. Some children may have somatic reactions and seek attention from the school nurse for stomach aches, headaches, nausea, or other complaints.
Pre-adolescence and Adolescence (ages 12 - 18)
This age group has a great need to appear competent to the world around them, especially to their family and friends. They struggle with the conflicts inherent in moving toward independence from parents on the one hand and the desire to maintain the dependence of childhood on the other. Approval and acceptance from friends are of paramount importance. Adolescents need to feel that their anxieties and fears are both appropriate and shared by their peers.
Disaster stress may be internalized and expressed through psychosomatic symptoms such as, gastrointestinal distress, headaches, skin problems, or vague aches and pains. Sleep problems such as insomnia, night terrors, or sleeping excessively may signal internal upset. Adolescents may turn to alcohol or drugs to cope with their anxiety and loss.
Social or school problems may also occur. Acting out or rebellious behavior may involve fighting with others, stealing, or power struggles with parents. Other adolescents may express their distress through withdrawal from friends and family and avoidance of previously enjoyed activities. School performance may decline. When the disaster causes major destruction of home and community, an older adolescent may postpone the developmental step of moving away from home.
Adults
Adults are focused on family, home, jobs, and financial security. Many are involved with caring for elderly parents as well. Pre-disaster life often involves maintaining a precarious balance between competing demands. Following a disaster, this balance is lost with the introduction of the enormous time, financial, physical, and emotional demands of recovery. Children in the family are in special need of attention and familiar routines, yet parents do not have enough hours in the day to accomplish all that is before them.
Over time, this stress overload can be manifested through physical symptoms of headaches, increased blood pressure, ulcers, gastrointestinal problems, and sleep disorders. Somatic reactions are especially present in those who are less able to experience and express their emotions directly. Cultural, gender-based, or psychological factors may interfere with emotional expression and seeking social support.
Emotional reactions often oscillate between numbness and intense expression. Anxiety and depression are common, as adults grapple with both anxiety about future threats and grief about the loss of home, lifestyle, or community. Anger and frustration about relief efforts abound, sometimes reflecting a displacement of the "less rational" anger that the disaster happened to them and was out of their control.
Older Adults
In the normal course of life, older adults typically have coped with losses prior to the disaster. They may have successfully adjusted to losses of employment, family, home, loved ones, or physical capabilities. For some, coping with these prior losses has strengthened resilience. For others, the prior losses may have worn down the individual's reserves and the disaster is an overwhelming blow (Norris et al., 1994). As a result of the disaster, irreplaceable possessions such as photographs or mementos passed on through generations may be destroyed. Pets or gardens developed over years may be lost. Mental health workers must recognize the special meaning of these losses, if they are to assist with grieving.
Older adults living on limited incomes tend to reside in dwellings that are susceptible to disaster hazards due to the location and age of the buildings. Because of financial limitations and age, they may not be able to afford the repairs to their homes. Leaving familiar surroundings is especially difficult for those who experience deficits in hearing, vision, or memory, because they rely on known environmental cues to continue living independently.
Many older adults fear that if their diminished physical or cognitive abilities are revealed, they risk loss of independence or being institutionalized. As a result, they may under report the full extent of their problems and needs. They may continue living in damaged or unsanitary conditions, because they do not have the physical strength, stamina, or cognitive organizational ability to undertake disaster clean up. Disaster mental health workers must carefully assess the range and full extent of problems in living faced by the older survivor. Often, concrete practical assistance for recovery, stabilization, and engagement with appropriate resources allows the older adult to continue living independently.
A larger proportion of older persons, as compared with younger age groups, have chronic illnesses that may worsen with the stress of a disaster, particularly when recovery extends over months. They are more likely to be taking medications that need to be replaced quickly following a disaster. While older adults may be in more need of multiple services for recovery, they are often especially reluctant to accept help and what they perceive as "handouts." Disaster mental health programs can more quickly gain acceptance when they work closely with known, trusted organizations and employ older adults as outreach workers.
Disaster Reactions and Intervention Suggestions
Age Groups
Behavioral Symptoms
Physical Symptoms
Emotional Symptoms
Intervention Options
PRESCHOOL
(1 - 5)
Resumption of bed-wetting, thumb sucking
Clinging to parents
Fears of the dark
Avoidance of sleeping alone
Increased crying
Loss of appetite
Stomach aches
Nausea
Sleep problems, nightmares
Speech difficulties
Tics
Anxiety
Fear
Irritability
Angry outbursts
Sadness
Withdrawal
Give verbal assurance and physical comfort
Provide comforting bedtime routines
Avoid unnecessary separations
Permit child to sleep in parents' room temporarily
Encourage expression regarding losses (i.e., deaths, pets, toys)
Monitor media exposure to disaster trauma
Encourage expression through play activities
CHILDHOOD
(6 - 11)
Decline in school performance
Aggressive behavior at home or school
Hyperactive or silly behavior
Whining, clinging, acting like a younger child
Increased competition with younger siblings for parents' attention
Change in appetite
Headaches
Stomach aches
Sleep disturbances, nightmares
School avoidance
Withdrawal from friends, familiar activities
Angry outbursts
Obsessive preoccupation with disaster, safety
Give additional attention and consideration
Relax expectations of performance at home and at school temporarily
Set gentle but firm limits for acting out behavior
Provide structured but undemanding home chores and rehabilitation activities
Encourage verbal and play expression of thoughts and feelings
Listen to the child's repeated retelling of disaster event
Involve the child in preparation of family emergency kit, home drills
Rehearse safety measures for future disasters
Develop school disaster program for peer support, expressive activities, education on disasters, preparedness planning, identifying at-risk children
Disaster Reactions and Intervention Suggestions (Continued)
Age Groups
Behavioral Symptoms
Physical Symptoms
Emotional Symptoms
Emotional Symptoms
PRE-ADOLESCENCE AND ADOLESCENCE
(12 - 18)
Decline in academic performance
Rebellion at home or school
Decline in previous responsible behavior
Agitation or decrease in energy level, apathy
Delinquent behavior
Social withdrawal
Appetite changes
Headaches
Gastrointestinal problems
Skin eruptions
Complaints of vague aches and pains
Sleep disorders
Loss of interest in peer social activities, hobbies, recreation
Sadness or depression
Resistance to authority
Feelings of inadequacy and helplessness
Give additional attention and consideration
Relax expectations of performance at home and school temporarily
Encourage discussion of disaster experiences with peers, significant adults
Avoid insistence on discussion of feelings with parents
Encourage physical activities
Rehearse family safety measures for future disasters
Encourage resumption of social activities, athletics, clubs, etc.
Encourage participation in community rehabilitation and reclamation work
Develop school programs for peer support and debriefing, preparedness planning, volunteer community recovery, identifying at-risk teens
ADULTS
Sleep problems
Avoidance of reminders
Excessive activity level
Crying easily
Increased conflicts with family
Hypervigilance
Isolation, withdrawal
Fatigue, exhaustion
Gastrointestinal distress
Appetite change
Somatic complaints
Worsening of chronic conditions
Depression, sadness
Irritability, anger
Anxiety, fear
Despair, hopelessness
Guilt, self doubt
Mood swings
Provide supportive listening and opportunity to talk in detail about disaster experiences
Assist with prioritizing and problem-solving
Offer assistance for family members to facilitate communication and effective functioning
Assess and refer when indicated
Provide information on disaster stress and coping, children's reactions and families
Provide information on referral resources
Disaster Reactions and Intervention Suggestions (Continued)
Age Groups
Behavioral Symptoms
Physical Symptoms
Emotional Symptoms
Intervention Options
OLDER ADULTS
Withdrawal and isolation
Reluctance to leave home
Mobility limitations
Relocation adjustment problems
Worsening of chronic illnesses
Sleep disorders
Memory problems
Somatic symptoms
More susceptible to hypo- and hyperthermia
Physical and sensory limitations (sight, hearing) interfere with recovery
Depression
Despair about losses
Apathy
Confusion, disorientation
Suspicion
Agitation, anger
Fears of institutionalization
Anxiety with unfamiliar surroundings
Embarrassment about receiving "hand outs"
Provide strong and persistent verbal reassurance
Provide orienting information
Use multiple assessment methods as problems may be under reported (e.g., repeat observations, geriatric screening questions, discussion with family)
Provide assistance with recovery of possessions
Assist in obtaining medical and financial assistance
Assist in reestablishing familial and social contacts
Give special attention to suitable residential relocation
Encourage discussion of disaster losses and expression of emotions
Provide and facilitate referrals for disaster assistance
Engage providers of transportation, chore services, meals programs, home health, and home visits as needed
Cultural and Ethnic Groups
Disaster mental health programs must respond specifically and sensitively to the various cultural groups affected by a disaster. In many disasters, ethnic and racial minority groups may be especially hard hit because of socioeconomic conditions that force the community to live in housing that is particularly vulnerable. Language barriers, suspicion of governmental programs due to prior experiences, rejection of outside interference or assistance, and differing cultural values often contribute to disaster outreach programs' difficulty in establishing access and acceptance. Communities that take pride in their self-reliance are reluctant to seek or accept help, especially from mental health workers.
Cultural sensitivity is conveyed when disaster information and application procedures are translated into primary spoken languages and available in non-written forms. Intense emotions are typically experienced and expressed in a person's language of origin, so outreach teams that include bilingual, bicultural staff, and translators are able to interact more effectively with disaster survivors. Whenever possible, it is preferable to work with trained translators rather than family members, especially children, because of privacy concerns regarding mental health issues and the importance of preserving family roles.
Cultural groups have considerable variation regarding views on loss, death, home, spiritual practices, use of particular words, grieving, celebrating, mental health, and helping. The role of the family, who is included in the family, and who makes decisions also varies. Elders and extended family play a significant role in some cultures, whereas isolated nuclear families are the decision-makers in others.
It is essential that disaster mental health workers learn about the cultural norms, traditions, local history, and community politics from leaders and social service workers indigenous to the groups they are serving. Program outreach workers and mental health staff are most effective when they are bilingual and bicultural. During the program development phase, establishing working relationships with trusted organizations, service providers, and community leaders is helpful. Being respectful, nonjudgmental, well informed, and following through on stated plans dependably are especially important for outreach workers.
Socioeconomic Groups
Many affluent, middle to upper middle class people live with a sense of security and see themselves as invulnerable to the devastation and tragedy associated with disasters. Because of their financial resources and life situations, they may have been protected from crises in the past, and have purchased insurance for "protection" in the future. They are more accustomed to planning and controlling life events, rather than unexpected overwhelming events controlling them. Shock, disbelief, self blame, and anger predominate in the hours and days following a major disaster, as the reality of losses, danger, and the work that lies ahead begins to sink in.
Higher income families may never have received assistance from social service agencies before. Accepting clothing, food, money, or shelter can be difficult and sobering. While they may need emergency assistance initially, they often do have social, financial, family, or other resources that engage quickly and buffer the disaster's impact.
Affluent families typically rely on known professionals for their support-their family physician, minister, or psychotherapist. Disaster mental health programs focus on educating local health care professionals and religious leaders about disaster stress, because these providers are most likely to encounter upper class survivors in need. Psychosocial Issues for Children and Families in Disaster: A Guide for the Primary Care Physician (CMHS, 1995) is an informative resource for training. Recovery programs can also coordinate disaster mental health counseling and support groups through these known and trusted entities.
In contrast, low-income survivors have fewer resources and greater pre-existing vulnerability when disaster strikes. While they may have developed more crisis survival skills than the more protected upper class individuals, they often lack the availability of support and housing from family and friends and do not have insurance coverage or monetary savings. Without these, the recovery process is even more arduous and prolonged, and sometimes impossible. Federal and State disaster assistance programs are designed to meet serious and urgent needs. The intent of these programs is not to replace all losses. Uninsured, poor families may have unmet needs and should be referred to non-profit disaster relief organizations and unmet needs committees. If they are renters, they may be faced with unaffordable increases in rent after landlords have invested money to repair their properties. They may be dislocated to temporary disaster housing that is undesirable and removed from their social supports. Relocation may make transportation and getting to appointments more difficult.
Faced with these multiple challenges and assistance that falls short of solving the problems before them, low-income disaster survivors can feel overwhelmed. For those with limited reading and writing abilities, obtaining accurate information and completing forms is difficult. Disaster mental health workers are most effective when they provide concrete problem-solving assistance that facilitates addressing priority needs. Workers must be knowledgeable about the full range of community resources available to people of limited economic means and actively engage this resource network with those in need.
People With Serious and Persistent Mental Illness
Clinical field experience has shown that disaster survivors with mental illness function fairly well following a disaster, if essential services have not been interrupted. People with mental illness have the same capacity to "rise to the occasion" and perform heroically as the general population during the immediate aftermath of the disaster. Many demonstrate an increased ability to handle this stress without an exacerbation of their mental illness, especially when they are able to maintain their medication regimens.
However, some survivors with mental illness have achieved only a tenuous balance before the disaster. The added stress of the disaster disrupts this balance; for some, additional mental health support services, medications, or hospitalization may be necessary to regain stability. For individuals diagnosed with Post Traumatic Stress Disorder (PTSD), disaster stimuli (e.g., helicopters, sirens) may trigger an exacerbation due to associations with prior traumatic events.
Many people with mental illness are vulnerable to sudden changes in their environment and routines. Orienting to new organizations and systems for disaster relief assistance can be difficult. Program planners need to be aware of how disaster services are being perceived and build bridges that facilitate access and referrals where necessary. Disaster mental health services designed for the general population are equally beneficial for those with mental illness; disaster stress affects all groups. In addition, when case managers and community mental health counselors have a solid understanding of disaster mental health issues, they are able to better provide services to this population following a disaster. Responding to the Needs of People with Serious and Persistent Mental Illness in Times of Major Disaster provides a comprehensive discussion of planning, preparedness, and options for service delivery with this population (CMHS, 1996).
Human Service and Disaster Relief Workers
Workers in all phases of disaster relief, whether in law enforcement, local government, emergency response, or victim support, experience considerable demands to meet the needs of the survivors and the community. Typically, disaster workers are altruistic, compassionate, and dedicated people who occasionally have difficulty knowing when it is time to take a break from the operation. For many, the disaster response takes precedence over all other responsibilities and activities. The brochure, Prevention and Control of Stress Among Emergency Workers-A Pamphlet for Workers, is an excellent resource for both disaster relief workers and mental health providers (NIMH, 1987). This brochure highlights the importance of having a personal emergency preparedness plan, so that workers are assured that their families are safe while they devote themselves to disaster relief for the community.
Relief workers may witness human tragedy and serious physical injuries, depending on the nature of the disaster and their role. This contributes to the psychological impact of their work. In disasters in which there is a high level of exposure to human suffering, injuries, and fatalities, providing psychological support and interventions for workers is especially necessary. In addition, relief workers and first responders should be considered a target group for ongoing services during the course of the disaster mental health recovery program.
As some order returns to the community, many workers, particularly volunteers, return to their regular jobs. However, they may attempt to continue with their disaster work. Over time, the result of this overwork can be the "burn-out" syndrome. This state of exhaustion, irritability, and fatigue creeps up unrecognized and can markedly decrease the individual's effectiveness and capability. These workers may be avoiding problems at home by working constantly. Disaster mental health workers should be on the lookout for workers whose coping resources have eroded due to their personal vulnerabilities and seemingly unrelenting workload. The next section in this manual, "Stress Prevention and Management," offers suggestions for identifying, educating, and intervening with those who may be having stress reactions and difficulty coping.
References and Recommended Reading
Bolin, R. & Bolton, P. Race, Religion and Ethnicity in Disaster Recovery. Colorado: University of Colorado Institute of Behavioral Science, 1986.
Center for Mental Health Services. Manual for Child Health Workers in Major Disasters. Washington, D.C.: U.S. Department of Health and Human Services; Publication No. (ADM) 86-1070. (Rev. ed. in press.)
Center for Mental Health Services. Responding to the Needs of People with Serious and Persistent Mental Illness in Times of Major Disaster. Washington, D.C.: U.S. Department of Health and Human Services; Publication No. (SMA) 96-3077, 1996.
Center for Mental Health Services. Psychosocial Issues for Children and Families in Disasters: A Guide for the Primary Care Physician. Washington, D.C.: US Department of Health and Human Services; Publication No. (SMA) 95-3022, 1995.
Gerrity, E. T. & Steinglass, P. Relocation stress following natural disasters. In: Ursano, R. J., McCaughey, B. G., & Fullerton, C. S. (Eds.). Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos. Great Britain: Cambridge University Press, 1994.
Gist, R. & Lubin, B. (Eds.). Psychological Aspects of Disaster. New York: John Wiley & Sons, 1989.
Green, B. L., Korol, M., Grace, M. C., Vary, M. G., Leonard, A. C., Gleser, G. C. & Smitson-Cohen, S. Children and disaster: Age, gender, and parental effects on PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 945-951, 1991.
Green, B. L. & Solomon, S. D. The mental health impact of natural and technological disasters. In Freedy, J. R. & Hobfoll (Eds.). Traumatic Stress: From Theory to Practice. New York: Plenum, 1995.
LaGreca, A. M., Vernberg, E. M., Silverman, W. K., Vogel, A. L. & Prinstein, M. J. Helping Children Prepare for and Cope with Natural Disasters: A Manual for Professionals Working with Elementary School Children. BellSouth Corporation, 1995. (To obtain copies: Contact Dr. La Greca, Department of Psychology, University of Miami, P.O. Box 248185, Coral Gables, FL 33124.)
Mitchell, J. & Bray, G. Emergency Services Stress: Guidelines for Preserving the Health and Careers of Emergency Services Personnel. New Jersey: Prentice-Hall, 1990.
National Institute of Mental Health. Prevention and Control of Stress Among Emergency Workers: A Pamphlet for Workers. Washington, D.C.: U. S. Department of Health and Human Services; Publication No. (ADM) 90-1497, 1987.
Norris, F. H., Phifer, J. F. & Kaniasty, K. Individual and community reactions to the Kentucky floods: Findings from a longitudinal study of older adults. In: Ursano, R. J., McCaughey, B. G., & Fullerton, C. S. (Eds.). Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos. Great Britain: Cambridge University Press, 1994.
Saylor, C. F. (Ed.). Children and Disasters. New York: Plenum Press, 1993.
Solomon, S. D. & Green, B. L. Mental health effects of natural and human-made disasters. PTSD Research Quarterly, 3 (1), 1-8, 1992.
Sue, D. W. & Sue, D. Counseling the Culturally Different: Theory and Practice. New York: Wiley, 1990.
Ursano, R. J., McCaughey, B. G., & Fullerton, C. S. (Eds.). Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos. Great Britain: Cambridge University Press, 1994.
U. S. Department of Health and Human Services. Action Plan of the Administration on Aging to Strengthen the Disaster Response Capacity to Serve Older People. Rockville, MD, 1994. Vogel, J. M. & Vernberg, E. M. Children's psychological responses to disasters. Journal of Clinical Child Psychology, 22(4), 464-484, 1993.
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