Integrating Ethical Research and
Practice
in
Disaster Mental Health
Peykan G. Gökalp
Bakırkoy Research and
Training Hospital for
Psychiatry and Neurology
Istanbul - Turkey
Main points
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Disaster studies from Turkey
Overall conclusion of the studies
ADEPSTEP, a services project on
disaster mental health
Some Q & A on ethics and disaster
research
Ethical evaluation of ADEPSTEP ( a
model)
Disaster and Mental Health
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Disasters strike the well being,
infrastructure, economy and most of
all mental health of the community
Mental health services are not
taylored for disaster survivors and
working on the field.
Studies before 1999
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Effects of the eathquake on the social structure of
the society Örnek et al. (1971) Burdur
“PTSD in earthquake survivors”
Veznedaroğlu et al. (1993) Erzincan ‘93
“Correlates of earthquake cognition and
preparedness in a victimized population”
Rustemli & Karancı (1999) Erzincan ‘93
“Dinar Earthquake and Expectations from Godot “
Aksit et al. 1997 Dinar ’95
“Preliminary report of stressor effects on
adolescent survivors of Dinar Earthquake”
Sener at al. (1997)
The investigation of acute stress disorder after
the 1998 Adana earthquake.
Uguz et al. (2000) Adana ‘98
Disaster Studies in Turkey
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1971 Burdur Earthquake (6.2)
Effects of the earthquake on the social structure
of the society
Örnek et al. (1971):
3 Psychiatrists made face to face interviews with 150
survivors in the first week after the disaster.
Results: social classes moved closer, the feeling of
solidarity increased.
88 % felt confusion,
15 % stood still,
63 % participated in rescue work
Audio records were made
1999 Marmara Earthquake (7.4)
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Ayatan 2000
Dindar 2000
Yucel et al. 2000
ADEPSTEP (Adapazarı) 2001
Hacıoglu 2001
Unlugedik 2001
Yigit 2000 GATA
Sezgin & Yuksel 2001
Tural et al. 2001
Basoglu et al. 2002
Karamustafalıoglu et al. 2002
Basoglu et al. 2003
Özguler 2003
Salcioglu et al. 2003
Risk factors for PTSD
Ayatan 2000
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n=151 (72.8% female, 27.2% male)
20 (13.2%) saved from the rubbles,
38 (25.2%) was wounded,
21 (13.9%) lost at least one member of the
family
Risk factors: low education, rescuers,
history of an anxiety disorder,
PTSD predictors
Dindar 2000: 3 weeks after the eq,
n=283 (61.5 % female, 38.5 %
male)
 Mean age: 32.68 ±12.22
 The immediate physiologic responses
(tremor / trembling) to the eq were
significantly related to PTSD
symptomatology.
The relationship between early phase PTSD
symptoms and predicting factors
Ünlügedik 2001
N= 285 (61.5 % female, 38.5 % male ),
interviews were conducted in 3 wk. after
the eq.
 Mean age: 32.68 ±12.22
 “Gender (female) is the most powerful
predictor for symptom severity”
Comorbidity in PTSD
Tural et al. 2001
• N= 76 (68.4 % female, 31.6 % male)
• Mean age:41.58±11.24
• Severely traumatized population
44.7 % saved from the rubbles, 9.2% severely
wounded, 23.7% lost a first degree relative, 22.4 % had
a first degree relative with a psychiatric disorder.
• 38.2 % had a comorbid disorder
• 28.9 % had a secondary m. Depression
• Predictors for comorbidity: loss of a close rel, physical
damage, being female, experiencing severe fear of
death
The natural course of PTSD
Karamustafalıoglu et al. 2003
 a follow up study
conducted in AvcılarIstanbul.
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9 422 people screened in
the first 3 months, 38.8 %
PTSD.
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15 453 people screened in
the 6-8. months post
disaster, 23.8 % PTSD.
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15 597 was screened in
the 18-20. months, 8.1 %
had PTSD.
The prevalence rate of PTSD
decreased with time.
40
35
30
25
20
PTSD %
15
10
5
0
1st asses 2nd asses 3rd asses
Predictors of PTSD symptom severity
Salcıoglu et al. 2003 (J Nerv Ment Dis)
 Prevalence rate of PTSD and Depression
was studied at 20. month after the eq
 586 were screened, who lived in a
prefabricated village
 39 % had PTSD, 18 % had depression
 PTSD symptom severity was higher in
women, elderly, rescuers, who had a
psychiatric history, who were saved from
the rubble and who felt an overwhelming
fear.
PTSD in elderly disaster survivors
Özgüler 2003
 n=90
 51 survivors(18-55 yo)
 39 survivors (>60 yo), who fullfilled
DSM lV PTSD criteria
 The symptom severity and frequency
decreased with age, younger adults
had more comorbid diagnoses.
Common features of the studies
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Focused on the prevalence of PTSD
Most published data have follow-up
assessments
Predictors for PTSD were discussed
Majority have unselected population
in the community as samples
Small number of research on
population from mental health
services.
Disaster studies with child survivors
after 1999
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Berkem & Bildik 2001
Yorbik at al. 1999
Laor et al. 2002 (Y.Yazgan)
Alyanak et al. 2000
Wolmer et al. 2003 (Y. Yazgan)
Yorbik et al. 2004
Child & adolescent studies:
Overall conclusion
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The perception and response to trauma
differs according to developmental factors.
DSM-IV criteria are insufficient to
diagnose PTSD for preschool children
Sleep disorders and pains were more
frequent with physical trauma
The duration of staying in the rubbles
caused emotional isolation
Trained teachers can help MH
professionals in determining child
survivors of disaster who needed help
Emirdag Prefabricated Village
Adapazarı
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Population:3000
Number of houses:
425
Area of a house:
36m2
Social service
houses: 10
Target population of Emirdag
• Poor
• Uneducated
• With no regular work and income
• Mostly without permanent house
• With high expectations of social
solutions
• With problematic health services use
ADEPSTEP
Yüksel, Sercan, Sezgin, Gökalp 2005
PSYCHOLOGICAL SUPPORT, SCREENING AND
TREATMENT PROJECT FOR POST-DISASTER MENTAL
HEALTH PROBLEMS IN ADAPAZARI
Objectives: inadequate mental health services in
the area.
 Supporting mental health facilities in the area
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Identifying risk groups for PTSD and other
Axis I disorders (Screening the unselected
traumatized population)
Treatment and counselling
Follow-up of those who need treatment for 1
year
ADEPSTEP
Project team: 14 volunteer psychiatrists and
psychologists from two institutions in
Istanbul
Support of NGO: Adapazarı Earthquake
Survivors Organization
Scientifically Supported by:
Psychiatric Association of Turkey
ESTSS
TMA
Financially Supported by: ACT Netherlands
ADEPSTEP
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Screening and Evaluation Instruments:
• Eartquake History Inventory (Sezgin&Yüksel,
2000)
• Posttraumatic Diagnosis Scale (Foa 1995 )
• Impact of Events Scale-R(Horowitz et al. 1979;
Marmar 1996)
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Diagnosis: DSM-IV
Follow-up Instruments:
• CGI
• HRSD, HRSA
ADEPSTEP
The screening : at 8th month after the
earthquake.
Those who were identified at risk were
interviewed again by a mental health
professional for diagnostic purposes and
treatment.
Those who needed medication were
followed –up for medication. Those who
were included in group therapy had
sessions every two weeks.
ADEPSTEP
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350 people were screened
71 % (n=247) were women
29 % (n=103) were men
Age: 37.45 (±12.8) R:16-80
Low income
Low-middle education status
Married, with average 2 children
Housewives (63.7%)
ADEPSTEP
Risk Factors for PTSD
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Being rescued from the rubbles
Being injured
Having a close other died near
her/himself
Having a close relative who died in
the earthquake
Participating in rescue efforts
ADEPSTEP
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59.7 % had PTSD
Those with medium and serious
symptom severity were 61.8 %
Those with medium and serious
functional impairment were 57.1 %.
Disaster mental health services in the field
“homework” questions !
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Is research needed on disaster mental
health ? Research is needed to understand the nature of
the reactions to disaster and the efficacy of the
interventions
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Did research emerge from these services?
What happened to surveys on the first
days of the disaster?
What happened to unpublished data and
information ?
Who publishes the Experiences?
WPA Disasters and Mental Health
More Questions
Are disaster survivors eligible for IC ?
Is the decisional capacity of survivors impaired?
Some survivors might have an impaired decisional
capacity due to the effects of acute stress.
Physical trauma, general medical instability might
worsen the situation, but cannot be generalized
(Rosenstein 2004).
The method of assessment for decisional capacity
should be stated (Yüksel 2005).
Some More Questions !!
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Are disaster survivors a “vulnerable”
population?
• No definite definition of vulnerability in
medical ethics.
• Vulnerability increases if social status, sense of
power, education level decrease.
• Helsinki Declaration: “ some groups of people
are more prone to be damaged from medical
research, therefore these people deserve more
protection and caution”
Disaster survivors might be more vulnerable in
the acute phase.
The ethical evaluation of
ADEPSTEP I
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The survey was planned as a services project,
focusing on the needs of the affected
population.
As stated in the Helsinki Declaration (WMA) a
high risk disadvantaged group who had no
other opportunity for treatment / professional
help was selected.
DEP-DER ( NGO formed by the earthquake
survivors of the area) was included and
consulted in every step of the project.
The members of the staff were chosen from
those who were experienced on trauma field
work.
Yüksel 2005 (in press)
ADEPSTEP (ethics) II
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Subjects who volunteered after the
introductory meeting and had full
capacity for informed consent were
included.
Those included were given clear
information on the process of
interviewing and treatment options.
It was observed that illiterate people
were confused with signing IC forms and
caused worry and suspicion.
The subjects had the right to exclude
themselves from the project at any step.
ADEPSTEP (ethics) III
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The calls for interviews were made by
DEP-DER which is an NGO with no
relation with official authorities.
Local resources were not used for any
need of the staff or the project.
The confidentialty issue was given
utmost importance although there were
practical difficulties. The charts were
kept in Istanbul and carried for every
visit.