Who needs help, of what sort, following a disaster?

The fourth installment in our series on disaster psychology shows how a lot of epidemiological knowledge got encapsulated in a simple, easy-to-use post-incident assessment.

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The mantra among disaster mental health devotees has seemed almost as like a peculiar contrapositive to the pronouncement of Lewis Carroll’s Dodo Bird that “All have won and all must have prizes.” In this case, it seems to be, “All have losses and all must have intervention.” But is that really the case? As with most things, it depends on how you look at it.

Disasters have many types of victims and, as a general rule, virtually all can make use of various types of help. The real question for our purposes here is: How many of these will require specific intervention for the psychological impacts of their disaster experience? Even that is a maultifaceted, multilayered question.

In the parlance of assessment, there’s a distinct difference between a sign and a symptom. A sign is an indicator that something is going on; a symptom is an indicator that something’s gone awry. Most of the indicators we recognize as symptoms of disorders such as PTSD are, at least in the beginning, only signs that a person is reacting to a demanding and disturbing set of challenges. They don’t become symptoms unless and until they fail to abate as the situation matures and resolves.

Although distress is common among those dealing with disaster, distress isn’t the same thing as dysfunction. It’s only when that distress is atypically broad, persistent and intense that it reaches a diagnosable threshold. Where we set these thresholds, and how we measure the intensity and persistence of distress, are questions all their own.

In the immediate aftermath of the 9/11 attacks, mental health spokespeople declared that one in four New Yorkers, and perhaps many more, would experience reactions such as PTSD and require treatment. But systematic epidemiologic studies showed that at four weeks, the current diagnostic threshold for persistence, only about 7.5% showed probable “caseness” (Galea et al, 2003). More significantly, by the time six months had passed, the original threshold for symptom persistence, only about 0.6% continued to show probable PTSD.

Put another way, 92% of those 7.5% who were likely to have been diagnosable under current standards had resolved their reactions to less-than-clinical levels of breadth and intensity by the original time threshold for symptom duration, typically without professional help or intervention. Indeed, the perceived underuse of the mental health services offered to New Yorkers following 9/11 has been one of the more intriguing “nonstories” of the episode (see, for example, Sommers & Satel, 2005).

There’s a legitimate question regarding whether directing people toward interventions touted as preventing PTSD is a wise use of resources if case conversion is relatively uncommon and spontaneous recovery is the dominant course. But where research has shown us that some of our most dominant intervention strategies (such as psychological debriefing) (a) are ineffective in achieving preventive impact and (b) potentially complicate recovery for significant subsets of victims, we have to ask whether such prophylactic approaches to intervention should be attempted at all.

Screening is always a sword that cuts both ways. Prostate Specific Antigen (PSA) screening for men in the fifth decade of life and beyond is a classic example. While it provides the potential for early detection of cancers that could be deadly, an even greater number of the malignancies found may never have had a significant clinical impact on the patient.

Prostate malignancies approach near inevitability as men age, and many more men die with prostate cancer than die of it. Interventions to treat a malignancy that the patient would otherwise never have noticed can have serious risks and profound impacts on the quality of life, while the anxiety created by the result makes "watchful waiting" an exercise in prolonged dread that many won’t choose to risk.

Fortunately, some screening instruments available now are simple to use, straightforward to score and decently selective. A good screening test must have good sensisitivity: It must be able to detect cases that are actually present. At the same time, it must have decent specificity: It must be able to find those cases without generating an undue number of "false positives" (cases that screen positively but do not have the condition).

For broad screens especially, we want high negative predictive validity (NPV). This means that those who screen negative for the condition are highly unlikely to manifest the condition or need treatment later. We also want decent positive predictive validity (PPV), even though we’re often more willing to accept a screen that indicates a need for further diagnostic testing where the “hit rate” is reasonably low and the NPV very high.

One such screening tool is the Trauma Screening Questionnaire (TSQ) developed by Chris Brewin and colleagues (2002) at University College, London. It’s a simple, 10-item screen composed of the indications associated with the arousal and re-experiencing criteria in the PTSD diagnostic rubric; one simply responds whether one has experienced each indicator at least twice in the past week.  Affirmative responses to any combination of six or more yields a positive screen. 

The TSQ’s brevity, simplicity of scoring and very good psychometric properties (as discussed above) make it an effective tool for use in disaster application centers (DACs) or primary-care clinics or even as a self-screening tool. Its creators have deliberately kept it in the public domain to facilitate its ready use without license or fees. You’ll find its content in the insert.

A good screen, though, is only helpful if it can result in timely referral to accessible and effective treatment. The good news is that we have well-researched, empirically established, evidence-based treatments for PTSD and depression, the primary conditions associated with disaster impacts. The bad news is that these treatments are not always available from the journeyman practitioners who provide the bulk of mental health care in any community. In the next installment, we’ll discuss efforts to bridge that gap.

Trauma Screening Questionnaire (Brewin et al., 2002).

References
Brewin, C. R., Rose, S., Andrews, B., Green, J., Tata, P., McEvedy, C., Turner, S., & Foa, E. B.  (2002).  Brief screening instrument for posttraumatic stress disorder.  British Journal of Psychiatry, 181, 158-162.

Galea, S.,  Vlahov, D., Resnick, H., Ahern, J., Susser, E., Gold, J., Bucuvalas, M., & Kilpatrick, D.  (2003).  Trends of probable post-traumatic stress disorder in  New York City after the September 11 terrorist attacks.  American Journal of Epidemiology, 158, 514-524.

Somers, C.H., & Satel, S.  (2005).  September 11, 2001:  The mental health crisis that wasn’t.  In C.H. Sommers & S. Satel, One nation under therapy (pp. 177-214).  New York, NY:  St. Martin’s Press.