By Professor Richard Bryant FAPS
School of Psychology, University of New South Wales

<< Return to InPsych April 2009

The recent bushfires in Victoria will undoubtedly lead to increased mental health problems in a significant proportion of those directly affected. There is overwhelming evidence that disasters can lead to a range of posttraumatic mental health problems. Over the past several decades, much research has informed us about the array of psychological problems arising from natural, and man-made, disasters.

Posttraumatic stress disorder (PTSD) is the most commonly identified disorder that occurs after exposure to a traumatic event. PTSD is characterised by re-experiencing of the traumatic event, avoidance, numbing and hyperarousal. Symptoms need to be present for at least one month and cause clinically significant distress or impairment in functioning to fulfil criteria for PTSD. Rates of PTSD have varied widely, which reflects the impact of different factors associated with events that can influence PTSD development. For example, rates of 53 per cent were reported after Ash Wednesday bushfires in 1983. Across studies, the prevalence of PTSD is higher among direct victims (30-40%) than rescue personnel (10-20%) (Neria, Nandi, & Galea, 2007). It is important to note, however, that other disorders also commonly occur both with PTSD, and independent of PTSD.

Depression is the second most commonly observed psychological disorder in survivors of disasters followed by various problems with anxiety (Norris, Friedman, Watson, Byrne, Diaz, & Kaniasty, 2002). For example, after the Oklahoma City Bombing, 22 per cent of people suffered depression, seven per cent suffered panic disorder, four per cent had generalised anxiety disorder, nine per cent had alcohol use disorder, and two per cent had drug use disorder; overall, 30 per cent of people had a psychiatric disorder other than PTSD.

One of the very tragic features of the recent fires in Victoria was the massive loss of life. Whereas grief is the normal response to the loss of a loved one, complicated grief refers to those reactions that persist over time. Complicated grief involves yearning for the deceased, bitterness about the loss, inability to proceed with life, preoccupation with the loss, hopelessness about the future, and preoccupation with sorrow. The available research suggests that complicated grief persists in approximately 10-15 per cent of bereaved people, however this rate will be markedly higher following traumatic death, as seen in the Victorian fires. Many studies have demonstrated that complicated grief symptoms form a distinct syndrome that is separate from depression or anxiety (Prigerson et al., 1999). Complicated grief can be a major problem because it is predictive of substantial morbidity (e.g., depression, suicidal ideation, high blood pressure), adverse health behaviours (e.g., increased smoking, alcohol consumption, insomnia), and quality of life impairment. Importantly, there are also distinct treatment responses, insofar as treatments that are effective for depression do not necessarily address symptoms of complicated grief.

It is also important to note that many survivors of massive disasters report other problems that may not be captured by traditional diagnostic categories. Sleep problems, worry, maladaptive substance use, and interpersonal conflict commonly occur after disasters. Although these may not be diagnosed as mental conditions, they can nonetheless contribute to very persistent problems affecting individuals, families and communities.

Trajectory of mental health responses

Prevalence estimates of mental disorders depend strongly on when the assessment is made. Generally, rates of PTSD are high in the initial months after a disaster but most become non cases in the subsequent months. For example, a survey of residents of New York City conducted five to eight weeks after the 9/11 terrorist attacks found that 7.5 per cent of a random sample of adults living south of 110th Street in Manhattan had developed PTSD. In February 2002, a follow-up study on another group of adults living south of 110th Street found that only 1.7 per cent of the sample had PTSD related to the attacks (Galea, Vlahov, Resnick, Ahern, Ezra, Gold, et al., 2003). A similar pattern was found in Thailand after the 2004 tsunami, where the rate of PTSD in displaced people was 12 per cent two months after the tsunami, but this rate dropped to seven per cent at nine months. This study also reported that depression decreased from 30 to 25 per cent, and anxiety decreased from 37 to 17 per cent.

These patterns have implications for when treatments are offered after disasters because most disaster survivors eventually regain functioning on their own without formal mental health intervention. It is for this reason that initial interventions are primarily designed to promote safety, assist coping and stabilise the individual and their environment. In contrast, subsequent interventions are designed more to prevent or treat psychopathological responses that have begun to emerge after the disaster. It is important to note that short- or intermediate-term intervention is not defined necessarily by time since a traumatic event. If a disaster is discrete and the effects are short-lived, then one may define a short-term intervention as occurring within days, and an intermediate intervention as occurring within a month. In the aftermath of a more extreme disaster that has longer lasting effects, it may not be appropriate to consider an intermediate intervention until several months has passed. Following Hurricane Katrina, for example, many people's lives were disrupted for lengthy periods because of relocation, lack of housing, and loss of basic infrastructure.

Two critical issues that are important for deciding the appropriateness of an intervention are the extent to which (a) the threat still exists for the survivor, and (b) the survivor has sufficient resources to manage the intervention. Survivors of the Victorian fires who have lost their homes, and much of their community, can be expected to experience persistent upheaval for months after the event. It is only when an individual has secured safety and an adequate sense of security and resources should one consider intermediate-phased interventions.

Identification of people who are at high risk for subsequent disorder

The evidence that most people will adapt in the months after a disaster poses a difficult challenge for early identification of survivors who will develop longer-term problems. Although the initial response involves provision of support for most survivors, targeted interventions aimed at prevention of subsequent disorders requires identifying those individuals who are having stress reactions that are precursors of longer-term problems. In an attempt to identify people who will subsequently develop PTSD, DSM-IV introduced the acute stress disorder (ASD) diagnosis to describe stress reactions in the initial month after a trauma. One goal of the diagnosis was to identify people who shortly after trauma exposure would subsequently develop PTSD. The requisite symptoms to meet criteria for ASD include three dissociative symptoms, one re-experiencing symptom, marked avoidance, marked anxiety or increased arousal, and evidence of significant distress or impairment. The disturbance must last for a minimum of two days and a maximum of four weeks, after which time a diagnosis of PTSD should be considered.

There are now many studies of adults and children that have prospectively assessed the relationship between ASD in the initial month after trauma, and development of subsequent PTSD (for a review, see Bryant, 2003). Although most people with ASD subsequently develop PTSD, the majority of people with PTSD do not initially display ASD. For this reason, the best way to identify people who will develop chronic PTSD may simply be to focus on those who display generally intense reactions after the event. Additionally, we do know from much research that other initial responses tend to be associated with more severe subsequent reactions, including extreme maladaptive appraisals about the experience, very strong arousal responses in the month after the event, pre-existing psychological vulnerabilities, and the lack of adequate social supports.

We know very little about early markers of other post-disaster disorders, such as depression, anxiety, substance use, and other problems. Further, the vast majority of studies of early markers of PTSD have emerged from studies of traumatic injury survivors rather than disaster survivors. For this reason, it is wise to implement ongoing surveillance of disaster survivors in the months after the event to monitor how they are adapting rather than relying on early identification. A major flaw in many previous disasters has been that many affected individuals have been missed by the health or recovery systems, and they have not sought treatment until years after the disaster. Given our poor ability to identify people who will eventually develop persistent problems, it can be most useful to ensure that people who are most directly affected by the disaster are monitored at subsequent time points, or that sufficient education is available to encourage people who are affected to seek appropriate help.

Ongoing stressors

It is very common in the aftermath of a disaster that survivors will experience a range of ongoing stressors that can compound their reaction. Relocation, loss of employment, pain, physical injury, legal procedures, and financial loss are some of the common burdens that disaster survivors may need to endure. There is considerable evidence that posttraumatic stress is compounded by the presence of stressors occurring in the posttraumatic phase. In the communities destroyed by the recent fires, there will be ongoing stress on those who have lost homes and communities as well as access to normal services (e.g., schools etc). We need to recognise that these ongoing events contribute directly to persistent adjustment difficulties and can persist for years. For example, in New Orleans many people are still suffering as a result of stressors that are secondary to Hurricane Katrina. People's mental health will undoubtedly be influenced, to varying degrees, by the effects of these ongoing stressors.

Concluding comment

Most people will eventually adapt after these fires. In the intermediate and longer-term periods, however, there will be a significant proportion of survivors who will experience a range of psychological and social difficulties. Fortunately, the field has developed a variety of evidence-based approaches to manage the range of these problems. Hopefully, all survivors who suffer persistent psychological problems will have access to mental health practitioners who can provide evidence-based strategies to facilitate their recovery.

The author can be contacted at r.bryant@unsw.edu.au.