# Presentation: 890932

## Research in Deployment Health and Stress-related Disorders

- Joseph I. Constans, Ph.D.
- South Central MIRECC
- 2006 Retreat

## Goals

-  Review (quickly) current projects
-  plug for Research Rounds
-  Discuss Hurricane Study

## Current Projects of MIRECC Investigators

-  Predicting PTSD Outcomes Using Objective Psychophysiologic Measures (Jeff Pyne - PI)
- Use of VR, cognitive, & psychophysiological paradigms
-  VA/NIH support
- Predicting PTSD course with non self-report based assessments
-  Arkansas National Guard
-  Bring VR technology to LR for treatment
-  Couples therapy for veterans with PTSD (Sautter – PI)
-  R21 submission
-  Collaboration between clinical / research teams

## Current Projects of MIRECC Investigators

- Cognitive Training Programs in the Treatment of Stress-Related Emotional Disorders (Constans - PI)
-  VA Merit Review
-  using computer-based training programs
-  allows for increased practice in changing pathological cognitions associated with depression and PTSD.
-  augment current therapies &  improve access to care?????
-  Treatment of co-morbid anxiety disorders in PTSD (Teng, Dunn, Bailey)
-  Panic control therapy
-  MIRECC support

## Impact of Hurricane Katrina on Gulf Coast veterans with and without pre-existing mental illness.

- Principal Investigator: Joseph Constans, Ph.D.
- Co-Investigators:
- 			Greer Sullivan, M.D.
- 			Jennifer Vasterling, Ph.D.
- Project Director: Elizabeth Deitch, Ph.D.
- VA Database managers:
- 			Teresa Hudson, Ph.D.
- 			Mark Austen
- Survey Development and Administration Consultant:
- 			Dana Perry, M.S.

## Hurricane Katrina

- The costliest & one of the most destructive hurricanes in U.S. history.
- Massive size; devastated Gulf Coast up to 100 miles from storm center.
- Over half of New Orleans flooded when levees breached.
- A number of Mississippi Gulf Coast communities were wiped out.
- Approximately 1720 people died in storm and aftermath.

## Immediate Stressors related to Hurricane Katrina

- Fear for life of self & others
- From storm itself, floodwaters, hunger, thirst
- Fear of crime and violence
- Looting, assaults, breakdowns of civil authority
- Breakdown of civil authority
- Exposure to bodies / potential contaminates
- Uncertainty & Ambiguity
- N.O. evacuation stretched to a month; status of homes, jobs, friends/family/pets uncertain.

## Prolonged Stressors related to Hurricane Katrina

- Loss of housing
- Temporary housing in trailers
- Permanent move
- Loss of employment / income
- Loss of belongings
- Furniture, sentimental items
- Loss of support system
- Neighborhoods & families split up
- Increased incidence of divorce

## Impact of Natural Disasterson Health

- Increased general distress
- Lasting >30 months
- Increased incidence of psychiatric disturbance
- PTSD (31%)
- Depression (30%)
- GAD (11%)
- Panic disorder (10%)
- Hurricane Andrew estimates (Davis et al., 1996)
- Poorer physical health outcomes
- Lower immune function
- Impaired sleep

## Risk factors for Poor Health Outcomes

- Severity of natural disaster
- Similar to relationship between combat / emotional disorders
- Severe disasters = more trauma & more loss
- Poor social support
- Katrina led to disruption of neighborhood networks, churches, social organizations
- Ethnic minority status
- New Orleans 73% African-American
- Lower SES
- 23% NO residents below poverty line
- Pre-existing mental illness
- Mostly using retrospective assessment
- Prospective studies emphasized depression
- Role of PTSD / Schizophrenia ????
- Unclear how pre-existing mental illness interacts with other risk factors

## Reactions to Katrina

- Diaspora = challenges for researchers.
- Eliminates face-to-face contact (Norris et al.)
- Changes in contact information
- Kessler, Galea, Jones, & Parker (2006)
- Use of cell phones for contacting residents
- Access to mental disorder incidence prior to storm
- Documented increases in mental disorders
- Found suicidal ideation did not increase proportionately
- Beliefs in post traumatic growth important moderator

##  Examining impact of Katrina on Gulf Coast veterans

- What is the health impact on veterans?
- What is the specific impact on veterans with psychiatric disturbances such as PTSD/ schizophrenia?
- Use of VA databases to identify +/- for pre-existing mental illness
- Allows for a prospective assessment
- Allows to assess possibly unique features of PTSD / schizophrenia
- Examine fit of current risk models
- Does psychiatric status impact other risk factors?

## Current Study Aims (1)

- Pre-existing mental illness (PMI) is a risk factor for developing new-onset disorders after natural disaster (Norris & Elrod, 2006).
- Veterans have not been specifically studied.
- It is unclear how veterans, especially those with combat stress, will react to disasters.
*Hypothesis 1: Veterans with PMI will show significantly higher rates of new-onset post- traumatic stress disorder (PTSD), major depressive disorder (MDD), panic disorder (PD), and generalized anxiety disorder (GAD) after Hurricane Katrina, as compared with veterans without evidence of PMI.*

## Current Study Aims (2)

- Other risk factors for post-disaster mental illness include lack of social support & negative cognitive appraisals (see review by Norris et al, 2002)
- PMI may be associated with these risk factors, contributing to negative outcomes.
*Hypothesis 2a: Veterans with PMI before Katrina will report lower levels of social support than veterans without PMI.*
*Hypothesis 2b: Veterans with PMI will engage in more negative cognitive appraisals of the impact of the hurricane and their actions and emotions in response to it, than will veterans without PMI.*

## Current Study Aims (3)

- Study includes exploratory investigation of relative impact of various risk factors, and whether risks are similar for those with and without PMI.
- Predictors of interest include:
- Severity of exposure to hurricane stressors
- Severity of ongoing stressors
- Social support
- Cognitive appraisals
- Financial resources

## Overview of Study Design

- Telephone survey
- experiences during & after Katrina
- Loss, social support, cognitive factors
- Current health / mental health functioning
- Administered by professional survey firm.
- 500 participants
- 250 with pre-existing mental illness
- 250 with no PMI.

## Participants

- 500 male veterans aged 18-60 as of 8/29/05
- Received services at N.O. or Biloxi VAMC.
- Resided in affected area at time of Katrina:
- LA parishes: Jefferson, Orleans, Plaquemines, St. Tammany, St. Bernard
- MS counties: Hancock, Harrison, Jackson
- MI positive cohort (n=250)
- 2+ visits to mental health clinic between 8/1/04-8/1/05
- Diagnosis of depression, PTSD, or psychotic disorder
- MI negative cohort (n=250)
- 2+ visits to primary care clinic between 8/1/04-8/1/05
- No mental illness diagnoses

## Survey Measures

- _Demographic Information_
- Age, sex, ethnicity, marital status, education
- _Employment/Income_
- Status at time of Katrina, current status, changes
- _Military History_
- Service branch, combat zone experience
- _Household Information_
- Living situation pre-K and now (location, structure, household members); extent of damage to home/possessions

## Survey Measures (cont’d)

- _Katrina trauma severity_
- Emotional events experienced (e.g., witnessing deaths, loss of friends/family/pets in storm
- Other traumas during storm & aftermath (e.g., assault, robbery)
- _Cognitive appraisals_
- Posttraumatic Cognitions Inventory (Foa, Clark, Tolin & Orsillo, 1999)
- Posttraumatic growth (Kessler, Galea et al., 2006)

## Survey Measures (cont’d)

- _Traumatic life events_
- Checklist of lifetime traumatic events other than Katrina (e.g., serious accident, assault).
- Modified version of Diagnostic Interview Schedule (CDC, 1989)
- _Post-traumatic stress disorder_
- Short PTSD Rating Interview (SPRINT; Connor & Davidson, 2001)
- _Generalized Anxiety Disorder_
- GAD-7 (Spitzer, Kroenke, Williams, & Lowe, 2006) assesses frequency of anxiety symptoms

## Survey Measures (cont’d)

- _Panic disorder_
- PD screen from Brief Patient Health Question-naire (Spitzer, Kroenke & Williams, 1999)
- _Depression_
- 2-item screen from Patient Health Questionnaire (PHQ-2; Kroenke , Spitzer & Williams, 2003)
- _Anger_
- Anger subscale of the Buss-Perry Aggression scale (Buss & Perry, 1992)

## Survey Measures (cont’d)

- _Perceived Social Support_
- 3 items each for emotional support, tangible support, & informational support.
- scale constructed by Norris & Kaniasty (1996) from items from the Interpersonal Support Evalu-ation List (Cohen & Hoberman, 1983) and Social Provisions Scale (Cutrona & Russell, 1987)
- _Alcohol Use_
- 3 items from Alcohol Use Disorders Identification Test (Babor, de la Fuente, Saunders & Grant,1989)
- Also, compare consumption pre- & post-Katrina

## Survey Measures (cont’d)

- _Physical Health_
- 9-item checklist for specific health problems (e.g., diabetes, cancer)
- 16-item measure for respondent evaluation of state of health; some original items and some from SF-12 Health Survey (Ware, Kosinski & Keller, 1996)

## Procedure: Participant Identification

- Using info from VA data warehouse
- 250 MI+ veterans will be randomly selected.
- PTSD, depression, psychotic disorder
- 250 MI- veterans
- Groups match MI+ cohort on age, ethnicity, zip code at time of Katrina, number of clinic visits.
- Names & contact info supplied to survey administration firm.

## Procedure: Contact Protocol

- Pre-notification letter sent to potential participants, allows opt-out by postcard or phone (wait 3-4 weeks).
- Interviewer will call, explain study, answer questions, obtain verbal informed consent.
- Survey will be administered as telephone interview (about 1 hour long).
- Address will be recorded to mail $20 compensation check.

## Procedure: Follow-Up Location

- For veterans
- Undeliverable mail
- Invalid phone numbers......
- Use of locator service (possibly using SSN).
- Second iteration of identification/enrollment:
- Generate list of names for 120% of remaining veterans needed to reach n=250 for each group.
- Follow contact protocol
- Repeat if necessary

## Challenges: VA Privacy/Security Issues

- New VA security directives: Implications for use of private survey administration firms.
- New requirements for storing any identified data anywhere outside the VA (e.g., that equipment is FISMA certified)
- Although survey data will be identified by a code number, not name, it will contain zip code information and so is not considered de-identified.
- Veterans’ names, addresses and SSNs may reside _***only***_*** ***on VA servers.

## Privacy/Security Issues

- Potential solution: in consultation with ISO, set up a Virtual Private Network (VPN) for the survey/locator company.
- Would give company limited access to a shared VA server where needed veterans’ info is stored.
- Survey data and address for compensation would be entered directly onto the VA server via the VPN.
- Would probably require that all users of the VPN complete VHA Privacy Policy Training and Cyber Security Awareness Training.

## Conclusion

- VA database provides information allowing for prospective design with regard to studying impact of disasters on those with prior mental illness.
- Significant challenges to accessing information in VA databases.
- Study will be first specifically investigating impact of disaster on veteran population.