Weathering the Storm — Understanding the Mental Health Impact of Hurricane Sandy

Coordinator:

Good afternoon and thank you for standing by. As a reminder your lines have been placed on a listen only mode until the question/answer segment of today’s conference call. This call is being recorded. If you have any objections you may disconnect at this time. I’d now like to turn the call over to Loretta Jackson-Brown.

Loretta Jackson Brown:

Thank you (Michelle). Good afternoon. I’m Loretta Jackson-Brown and I’m representing the Commission Outreach and Communication Activity -- COCA -- with Emergency Risk Communications Branch at the Center for Disease Control and Prevention. I’m delighted to welcome you to today’s COCA call Weathering the Storm, Understanding the Mental Health Impact of Hurricane Sandy.

You may participate in today’s presentation by audio only, via webinar or you may download the slides if you’re unable to access the webinar. The PowerPoint slide set in the webinar link can be found on our COCA webpage at emergency.cdc.gov/coca. Click on go on September 17 COCA call. The slide set is located under call materials.

Continued education is offered for this COCA call. Instructions on how to earn continued education will be provided at the end of the call.

CDC, our planner, presenters, and their spouse’s partners wish to disclose they have no financial interest or other relationship with the manufacture of commercial products, suppliers of commercial services or commercial supporters with the exception of Dr. Schwartz and Dr. Gwynn. They would like to disclose that they’ve received grant funding from CDC through their institution to conduct these studies. Planners have reviewed content to ensure there’s no bias. This presentation won’t include any discussion of the unlabeled use of our product or product under investigational use.

At the end of the presentation you’ll have the opportunity to ask a presenter’s question on the phone dialing. Star 1 will put you in the queue for questions. You may submit questions through the webinar system at any time during the presentation by selecting the Q&A tab at the top of the webinar screen and typing in your question.

At the conclusion of the session the participant will be able to discuss the vulnerability factor to mental health issues after Hurricane Sandy, describe how administrative data from emergency department can be utilized for public health purposes, describe the groups who are most at risk for mental health issues after the storm and describe how local disaster preparedness and response activities can address the mental health needs of residents who are impacted by disasters.

At this time I’d like to introduce Hussain Yusef, an epidemiologist in the extramural program office in the Office of Public Health preparedness and response at CDC. Dr. Yusef will provide an overview and introduce the presenters for today’s COCA call. At this time please welcome Dr. Yusef.

Hussain Yusuf:

Good afternoon. Today’s call will present findings from research sponsored by the Center for Disease Control and Prevention. In the aftermath of Hurricane Sandy the CDC along with the Office of the Assistant Secretary for Preparedness and Response, and the National Institute of Health sponsored the Hurricane Sandy response and recovery research. The purpose of this research is to inform and strengthen in the public health emergency response and recovery activity of the affected communities and to strengthen their preparedness for possible future emergencies. The research conducted will also help to strengthen the preparedness response and recovery capabilities of the nation in general. A specific focus of the research was to examine the mental health impact of the storm. The two presentations in today’s call will present research findings in this context. The ideas expressed in the presentations are those of the authors and don’t necessarily reflect the official position of the CDC.

The first presentation is by Dr. Rebecca Schwartz. Dr. Schwartz is a clinical psychologist and Associate Professor in the Department of Occupational Medicine, Epidemiology, and Prevention North Shore LIJ Health System. Dr. Schwartz earned her Bachelor’s degree from the University of Pennsylvania and her PhD degree from the University of Illinois of Chicago.

The second presentation will be by Dr. Charon Gwynn. Dr. Gwynn is a Deputy Commissioner at the New York City Department of Health and Mental Hygiene. Dr. Gwynn completed her Bachelor’s degree at MIT and her Masters and PhD degrees at NYU. At this time I’d like to invite Dr. Schwartz to begin her presentation.

Rebecca Schwartz:

Thanks so much. Thank you for having me here today. Today I’m going to be talking about our project, Project LIGHT which focuses on understanding the mental health impact of the hurricane on residents of Nassau and Suffolk counties of Long Island as well as areas of Queens County in New York City and Staten Island County in New York City.

The PI for the project is Dr. Emanuela Taioli and the co-PI is myself. The initial focus and title of our project was understanding the psychological sequelae of the impact of Hurricane Sandy. However when meeting with our community stakeholders and our various community advisors we decided that was too big of a mouthful. So we decided to come up with another name and this stems from the community and we decided to call our project Project LIGHT which stands for Leaders and Gathering Hope Together.

This is a partnership which means Dr. Taioli and myself, she’s at Mount Sinai and I’m at North Shore LIJ as well as our community partner who’s another co-PI, commissioner Lisa Murphy who’s the commissioner of the Nassau County Department of Human Services. We do have a website that describes our project as well as some of the presentations and some of the outcomes that we’ve come up with thus far. And again just to reiterate the funding for our project was supported by the Center for Disease Control and Prevention under a UO1 grant.

The objective of the study was to understand the psychological impact of the hurricane in order to form current intervention efforts as well as future intervention efforts. There’s three overall aims. The first aim which is the one I’ll be mostly focused on today was to assess the psychological and behavioral effects of the hurricane on the residents in the geographical areas I just named.

This was done using a population based survey which I’ll describe soon. The second aim was to examine the prevalence of specific mental health diagnoses presenting to local emergency departments in the affected counties and the third aim was really to combine the results of aims 1 and 2 to develop a vulnerability profile based on the results of aim 1 and aim 2 as well as to develop the Hurricane Sandy cohort database that could be utilized by other researchers as well as potentially other public health stakeholders.

Aim 3 is currently in process now. We’re towards the end of all our data analysis. Today I’ll be mostly focusing on the results of aim 1. So in terms of aim 1 we recruited approximately 670 study participants. All were adults over age 18 and again the standpoint areas were Nassau and Suffolk counties as well as Queens and Staten Island.

We purposely conducted standpoints on both heavily affected and mildly affected areas to ensure that we had some variability in terms of exposure to the hurricane. Given that we weren’t - we didn’t know that the hurricane was going to hit we weren’t in place prior to the hurricane our recruitment strategy is from a convenient standpoint at various community sites and events.

It wasn’t part of an ongoing study. However through the - our partnership with the Nassau County Department of Human Services as well as many contacts that we developed with local community stakeholders we were really able to hit the ground running in terms of recruitment and it allowed us to be very successful in terms of our numbers in recruitment.

Every participant completes a questionnaire. Usually they complete it themselves. In the case where literacy or eyesight was an issue it was read aloud by one of our research staff. The questionnaire sections asked about basic demographic information, a little bit about occupational and environmental - where the person’s living as well as a few questions about medical history.

Then we also asked about our main outcomes which include behavioral health, substance use, alcohol use, tobacco use as well as perceived stress, depression, anxiety, post-traumatic stress disorder symptoms, current mental health status as well as previous mental health history.

And then we also asked some questions about post-traumatic growth that really assesses whether or not there’s actually positive growth as a result of having experienced a negative event. And then finally we asked a series of questions which I’ll describe further in a minute regarding what exactly happened to the person during Hurricane Sandy.

As I mentioned our total sample size through the end of project recruitment was 669. We do have majority female participants. We have about 64% female. The reason for that really has to do with convenient sampling and the fact that females historically are more willing to participate in research projects. We did try to account for this disparity by trying to recruit later in the afternoon evening, not during working hours and go to venues where we thought that there’d be more males.

The race and ethnicity of our sample reflect the health system - the North Shore LIJ health system and the counties for the most part that we were more heavily in which are Nassau and Suffolk. The main age was 47 and our age range was from 18-104.

In terms of hurricane exposure there was a - we used a 30 item tool which assessed where each participant had to check off whether or not the particular event happened to them during the hurricane. This slide is a sample of some of those items and it just shows you the variability in terms of exposure and in terms of specific events that happened.

It was very common to have lost electricity. The vast majority of our sample, 71%, lost electricity, 30.5% were displaced from their home. Having a family member missing or physical harm to a family member were much lower, 1.8% and 4.5%. Overall mean - 20 not 30 items was 3.8 items that were endorsed.

We did something called the principle components analysis to see if our Hurricane Sandy exposure tool divided into different categories and what we found is that it did. Some of the items really had to do with damage to property and some had to do with impacts on personal. So the personal items for example were things like something happened to a family member or a pet or had to evacuate quickly without being prepared.

The property items had to do with damage to your home, damage to your vehicle, loss of employment, things along those lines. As you can see the mean was higher at 3.1 as compared to 0.93 for property damages. Someone just moved my slide forward. If you could just let me move my slide, thank you. Okay.

In terms of our mental health outcome, just to give you an overall picture of our population, in terms of the perceived stress scale which is a validated known measure of perceived stress that’s been used widely in research, the mean of our sample was 15.6. The general population mean is 13 so that gives you a sense that the stress level was a little bit higher among those that we sampled. Keep in mind when we started sampling it was about a year after the hurricane to two years after the hurricane. So there was a period of time that a year had lapsed until we got the funding and got the study going.

Even still you can see that in general in this population of those that we sampled the stress level were still a little higher. In terms of anxiety we used the PHQ-4, again a well validated measure. The first two items of the PHQ-4 have to do with the anxiety symptoms so the second has to do with depression symptoms. The mean for our sample was 1.6 and a mean of greater than or equal to 2 indicates probable anxiety and that was the case for 47.5% of our sample.

In terms of depression symptoms our mean was 1.2 and again a mean of greater than or equal to 2 indicates probable depression and that was 34% of our sample, again used rates of 37 and 34% is much higher than the general population. We assessed post-traumatic stress disorder symptoms.

We used a measure called the PCLC which was - and we used it in the specific version, the S version which is actually a version that we used that was anchored to Hurricane Sandy. So it asked about specific symptoms of post-traumatic stress disorder as it related to Hurricane Sandy. So it wasn’t a person who had post-traumatic stress disorder from a different event would score high on this because this is all related back to Hurricane Sandy.

The mean for our sample was 25. A mean of greater or equal to 30 indicated probable post-traumatic stress disorder and that was the case for about 20.5% of our sample. So without getting into too much detail about the numbers here the main thing to look at was that across our three main outcomes, depression, anxiety and post-traumatic stress disorder, even after considering the impact of factors that we know have an effect on these kinds of mental health outcomes such as age, gender, education, race, ethnicity and the biggest one is having a previous mental health history is most highly associated with current mental health problems.

Even after considering the impact of all those exposure to the hurricane was still associated with all three of our outcomes. So if you look across the bottom - the bottom row you can see the odd ratios there were modest. However they were statistically significant so greater hurricane exposure was associated with greater depression symptoms, greater anxiety and greater likelihood of post-traumatic stress disorder symptoms.

When we divided this - when we divided up these findings by sex we really found that there wasn’t very much in terms of differences in terms of females. We still found that hurricane exposure was significantly associated with all of our outcomes and it was among males as well with the exception of depression. Among males hurricane exposure wasn’t associated with depression. However it was with anxiety and post-traumatic stress disorders.

I’m going to shift now for a minute to our emergency data findings. Basically we used data from all emergency departments in New York state between 2009, 2013 to see - 23 emergency departments that were located in New York state but that were actually located in Nassau and Suffolk County. We wanted to see if there were differential patterns of emergency utilization during - before, during and after the hurricane that were different from previous years.

What we found in general was that there was a drop on the day of the hurricane but a large spike the immediate day after the hurricane with an access of 773 emergency department visits in one of those 23 emergency departments. And you can see this here on the graph that goes by date that there’s a big spike right after the hurricane hit.

This has implications in terms of staffing and emergency department utilization. We have a lot of our community stakeholders really felt that this had a lot to do with utilizing the emergency department for reasons that maybe weren’t normally reasons to utilize the emergency department just due to lack of access to other medical care such as people who are insulin dependent and people who just for whatever reason really needed electricity.

The most significant result was among - in terms of all the different diagnoses that were presented in the ER during this time, the only one that was significant was disease of respiratory system which we did show an increase for in the period during and immediately after Hurricane Sandy. The mental health presentation weren’t actually significantly different in terms of findings from previous years during the same time period. The one significant diagnosis was respiratory symptoms.

As I mentioned before we have a third aim which is really trying to assess even among those that were all highly exposed to the hurricane where there’s certain subgroups that were more vulnerable to mental health effects. We have found so far that there’s certain factors that are placing people at a higher risk.

One is having a previous history of mental health difficulties. We also found that from depending on the specific outcome whether it’s anxiety, post-traumatic stress disorder or depression, we found that Hispanic ethnicity, non-white race, lower education, female sex and actually lower age was significantly associated with some of the more negative mental health findings.

We anticipated however that seniors would be more vulnerable in the population. We didn’t find this result and I can talk about why that might be in a minute. Just to give you a brief background, in terms of Hurricane Sandy of the 44 people who died during the hurricane over 70% were 55 or older. Again seniors reported worsening of a health condition due to Hurricane Sandy at three times the rate of those under 65. Interruptions and access to prescription medications had serious consequences for seniors. In addition transportation was a huge issue. There’s really inadequate contingency plans for seniors who had exacerbated chronic conditions, for example getting to dialysis centers was very difficult.

Many home care workers and caregivers were unable to reach seniors who they cared for due to all the issues with access to roads and gas shortages. Also in addition there’s - overall there’s under-enrollment among the elderly to benefit programs and eligibility at a greater disadvantage when dealing with property damage and problems following the storm. Seniors were also relatively reluctant to evacuate.

To comment on this though, we actually found that younger folks who participated in that study seemed to have more negative mental health impact from the storm. And we believe that this actually may have more to do with our sampling strategy than actual findings. Most of our seniors in the study - and we did have a fair number.

As you might’ve noticed our age range went up to 104. Most of the seniors in our study actually resided in senior housing or were associated with senior centers and we collected the data at the senior center. And we believe that having that link to those support systems and those resources made them maybe less vulnerable than other seniors who maybe were isolated and living alone. So we feel that might’ve had an impact on our particular findings.

So overall we did find that Hurricane Sandy - increased exposure to Hurricane Sandy was significantly associated with increased mental health difficulties across all of our outcomes stress, anxiety, depression, post-traumatic stress disorder even after adjusting for factors known to be associated with mental health.

In terms of vulnerability having a history of mental health difficulties, lower education, younger age were the most consistently associated with poor mental health outcomes across most of the outcomes. And emergency department data showed an increased utilization immediately after Hurricane Sandy with a particular increase in presenting illness in terms of respiratory disease.

One of the reasons that our project was such a success is that we worked very closely with a project advisory committee which consisted of community stakeholders representing all different people throughout our region whether they’re involved in mental health, service provision, public health, emergency preparedness, first response or from a research background and they - the various stakeholders sat on all of our different committees and really contributed immensely to our project in every step.

This is our project team. Up in the right hand corner is some of our staff will go out into the field and on the lower left corner are our partners in the Nassau County Department of Human Services with Commissioner Lisa Murphy in the middle and Dr. Emanuela Taioli and I are up at the top and that’s it. Thank you very much for your time. I’m now going to turn it over to Dr. Gwynn. I’ll look forward to answering any questions at the end.

Charon Gwynn:

Thank you so much Dr. Schwartz. I’m excited to talk to you today about some work that’s very complementary to the work that Dr. Schwartz just presented talking about the impact of Hurricane Sandy on mental health in New York City.

Before I start I wanted to acknowledge the co-investigators and contributors to this work. Specifically I wanted to highlight Shakara Brown who is the main analyst behind this work as well as Hillary Parton and Megan Affrunti. This work is also supported by the CDC grant that was discussed earlier.

As has been mentioned and I think as many know Sandy was an unprecedented natural disaster in New York City. There was a mandatory evacuation order issued for everyone in Zone A the day before landfall, October 28 and when the storm hit on the 29th the city experienced various impacts on the built environment and the flooding exceeded the map evacuation zone.

Some areas that were hit particularly hard are the Brooklyn, Queens waterfront, east and south shore of Staten Island, south Queens, southern Bronx and southern Manhattan. The physical and economic damage was pretty expensive and long lasting and impacts included death, injury and mental health outcomes.

Just some quick background, symptoms - mental health symptoms have been shown to occur among some people who have lived through disasters. They’re commonly short in duration and improve over time. However some may experience delayed symptom onset. The most commonly described mental health symptoms include post-traumatic stress disorder, depression, psychological distress or serious psychological distress which we call SPD.

There’s some groups that are shown to be at higher risk for developing symptoms including females, those who have experienced prior mental health issues or physical health impairment, those in lower socioeconomic status (SES) status and those who experienced direct exposure to traumatic events either injury or through witnessing traumatic events.

So with that background we really wanted to try to characterize mental health impacts of Sandy in New York City. As Dr. Schwartz described it’s hard to design a study that’s very well designed to assess something like a natural disaster. So we wanted to use various resources that we either collect routinely or were able to collect after the storm to try to describe the mental health outcomes from Hurricane Sandy.

Our first research aim was to characterize mental health outcomes among New York City residents and identify those most impacted by Hurricane Sandy. Our second aim was to describe evacuation strategies and assess the impact of mental health outcomes among New York City residents and then third to describe crisis - calls that were made to our crisis hotline called LifeNet among New York City residents following Sandy.

But before I go into methods I wanted to describe the definitions for the affected areas that were used in this work. There’s an inundation zone which was actually defined by FEMA after Sandy which was quite extensive and there was the evacuation zone which was actually designed before Sandy by New York City to plan for a hurricane and there were three evacuation zones, Zones A, B, and C - delineated according to risk of impact.

As I mentioned there was a mandatory evacuation for Sandy and New York City officials alerted Zone A residents. So 155,000 emergency alerts were sent and 375,000 residents were ordered to evacuate.

So as I mentioned we tried to utilize information that we routinely collect to understand the mental health impacts. We conduct an annual survey here in New York City called the community health survey and it’s conducted annually. It’s a random digital survey and it assesses a broad range of chronic illnesses, behaviors, risk factors and mental health outcomes.

We did collect information on Zone A residents during Irene and Sandy during the CHS years of 2012 and 2013. And for the CHS we compared evacuation for Hurricane Sandy and Irene in Zone A and we also looked at serious psychological distress among those who evacuated and those who didn’t evacuate.

We also tried to implement a quick assessment after Sandy called the community assessment for public health emergency response survey or CASPER. This is a needs assessment survey that was implemented in areas that were most affected by Sandy. We collected data on 420 adults from 1000 households in south Bronx and Rockaway and Staten Island after Sandy and we included questions on trauma during the storm, storm related stressors, PTSD, serious psychological distress, general anxiety disorder, depression.

Here we focused our analysis on those in the FEMA defined inundation zone and we looked at the prevalence of PTSD, SPD, depression, stressors and exposures from Sandy and prior trauma and evacuation behaviors. Our third aim was to try to assess the impact of Sandy on mental health using calls to LifeNet.

LifeNet is a free confidential 24 hour crisis hotline that’s provided by the Mental Health Association and the Department of Health. And it assesses mental health conditions and it can provide mental health referrals as well as those for substance use.

We analyzed data from LifeNet calls. We used phone numbers and we looked for area codes from the five New York City counties. And we searched text for keywords including hurricane, storm, flood and damages and we calculated the total number of calls and the proportion of calls with mental health and substance use issues.

First I’m going to talk about the mental health measures that we captured through the community health survey and through CASPER. So for both Irene and Sandy the prevalence of serious psychological distress didn’t differ by evacuation zone. We see here that they’re both 7%. When we look at CASPER we see much higher numbers.

We see that serious psychological distress is 15%, depression is 22% and post-traumatic stress disorder is 26%. And so those higher numbers are on par with I think some of the numbers that Dr. Schwartz just showed although they’re not exactly the same and that likely is due to different methodologies that were used.

We also found that prevalence of SPD and PTSD were related to storm-related traumatic events and stressors. And those - prevalence increased when we saw increasing traumatic event exposures including experiencing a physical injury, witnessing something terrible, someone you loved or somebody you thought was killed or you thought they might be killed or if you had a stressor due to Hurricane Sandy including being displaced or experienced damage to your house or flooding.

When we looked at SPD by zone we found that for both Irene and Sandy serious psychological distress in Zone A was similar to those outside of Zone A so we didn’t see any difference in the mental health burden in those two areas. And when we looked at the data from CASPER, we found that post-traumatic stress disorder and depression were higher in the inundation area when we compared that to national levels and both were higher when we talked about the storm-related traumatic events and stressors.

Looking at evacuation and mental health we found - first when we describe evacuation in the general population we found that 31% of Zone A residents evacuated during Irene and this compares to 37% of Zone A residents that evacuated during Sandy. Of those who did evacuate during Sandy we found that 53% left before Sandy hit New York City and 61% were displaced for more than a week.

We did also find as was previously mentioned that older adults were less likely to evacuate than younger adults. And this slide basically shows that the characters - the evacuation rates by key characteristics. And here again you see that the older adult age group is much less likely to evacuate. We did see some trends by gender but these weren’t significant. So we did see that females had higher evacuation (unintelligible) than males but those weren’t significant.

This data is from CASPER and here we see the information that we’re getting from CASPER is higher than what we saw on some of the community health survey, 49% of residents evacuated as they found from CASPER.

We found that only 25% overall evacuated before the storm. When we looked at evacuation and mental health we found that people who did and didn’t evacuate from Zone A during Sandy had similar levels of psychological distress from the community health survey. And then when we looked by inundation zone through CASPER we found that those who did and didn’t evacuate had similar levels of psychological distress, depression and post-traumatic stress disorder.

Now we want to look at the third aim, LifeNet calls. We looked at LifeNet calls received a few days prior to Sandy’s landfall and then through the following calendar year to try to capture all possible calls. In total we found that 2159 calls were received. We also saw a bump in February and April in the number of calls and that’s relating to outreach efforts to providers and project HOPE which was a crisis counseling assistance and training program that was developed to try to address the mental health issues of those hard hit by Hurricane Sandy.

When we looked by mental health concern we found that most Sandy related calls were due to bipolar and related disorder and anxiety. Fewer calls were received for other mental health issues which include psychological stressors, relational problems and sexual disorders and for substance use, trauma-related disorder and all others.

We also tried to assess the level of care that LifeNet callers were receiving. These callers were asked about the care that they received and among those calling for mental health issues about 1 in 3 reported having no care from a mental health care -- this is about 33% -- had no level of care. So we’re seeing significant unmet need in people who are experiencing impacts of Hurricane Sandy.

As part of the call risk assessments are done to all callers for LifeNet and that includes a mental health and a suicide risk assessment. You can see here in the blue that 91% of callers received a suicide risk assessment and 2% received only a mental health risk assessment. So the assessments of suicide and mental health aren’t mutually exclusive. About 89% of callers included a mental health assessment and most of those were within the 91% that were assessed for suicide also.

The caller is also assessed for protective factors that they may have. This was selected by the LifeNet mental health professional. Here we see that - we see that family, social support, counseling and having goals for the future are most commonly reported protected factors for suicide. Those three total about 52%.

We did have some limitations and are - the way we collected the data. The CHS and CASPER are surveys. They do have different sampling methods. They sample different areas so they might not be directly comparable and they might not necessarily be representative. We did experience some small cell sizes so it’s really difficult to describe certain outcomes especially if we’re stratifying.

Each data source had different outcomes of interest. LifeNet calls were also subject to limitations. It was difficult to classify Sandy related calls because LifeNet isn’t really designed to be a tool used to assess impacts of disaster and the true nature of the call may not have been captured by the text/field searches that we did.

An ability of the reported primary health concerns were unclear so the reasons weren’t mutually exclusive. Another issue is that we might not have gotten all of - we might’ve not been able to truly classify resident callers as being residents of New York because we weren’t able to differentiate landlines from cell phones. In summary we found that the prevalence of mental health outcomes among respondents in the inundation zone was higher than national levels. We also found that a prevalence of SPD and PTSD was higher among those with storm-related traumatic events and stressors.

When we talked about evacuation we found that 31% evacuated during Irene. Uh oh. My slide seems to be gone but I’ll continue on. Okay, there we go. Thirty-one and 37 evacuated during Sandy. However in CASPER we found that 49% evacuated from the evacuation zone.

We also found that mental health, when we look at mental health by evacuation status, there was no significant difference in prevalence of mental health outcomes by evacuation area. And then when we looked at LifeNet callers we found that 1/3 of callers with mental health outcomes reported receiving no care. However social support, counseling and having goals in the future were common protector factors. I think I can just skip my last slide. I’ll wrap up.

Loretta Jackson Brown:

Yes. If you happen to sign in on the participant [presenter] code, please no participant move the slides. Thank you.

Charon Gwynn:

Thank you. And so in terms of implications I think this work is helping to try to understand the vulnerable populations for future storm events, that we really need clear and specific communication about evacuation and protective actions. The evacuation rate is considerably low. We’re doing some work as the - the Health Department to try to make sure that we’re targeting and aiding at-risk populations including linking to mental health services.

I do want to mention a couple of efforts that we have including citywide canvassing that we’re preparing for to make sure that we’re assessing critical needs impacted population after disaster and we’re encouraging people - we continue to encourage people to know their zone so that people can be aware of their zones and know how to respond. And we also have a website for New York City residents to try to prepare them to respond to disaster and provide information of potential likely threats to New York. So with that I’ll end. Sorry I moved it one too far and I’ll hand it back over to Loretta.

Loretta Jackson Brown:

Thank you presenters for providing our COCA audience with such a wealth of information. We’ll now open up the line for the question and answer session. When asking a question please state your organization and also remember you can submit questions through the webinar system as well. Operator?

Coordinator:

Thank you. At this time if you do have any questions or comments please press star 1 on your touch tone phone, again that’s star 1.

Loretta Jackson Brown:

While we’re waiting for the operator to let us have the first question I do want to generate some discussion around the level of depression. And perhaps Dr. Gwynn you can speak to why the level of depression was so much higher in the inundation zone compared to the evacuation Zone A.

Charon Gwynn:

Sure, yes. As I showed in the slide we did have much higher depression in the inundation zone. That was identified through CASPER. I think you have to remember that the CASPER was a survey that was done after Sandy and it was focused on the hardest hit areas and it was focused on the inundation zone.

So the inundation zone was the area that was defined after Sandy where the community health survey focused on Zone A which is the Zone that was defined before Sandy. And so maybe I think we suspected some of the difference we see is because we’re talking about more harder hit areas versus areas that may have or may not have been hardest hit but there’s also possibilities that there’s differences and the methodology in how these gone about coming up with these estimates.

Loretta Jackson Brown:

Thank you. Operator?

Coordinator:

We do have one question. Again that’s star 1 on your touch tone phone if you do have any questions. Jamar you may go ahead.

Jamar:

Yes hello. I have a question about the conclusions drawn from this. Does this also apply to a man-made disaster like terrorism?

Rebecca Schwartz:

Should I take this first? This is Dr. Schwartz. I think what we know from man-made disasters, a lot of the literature coming out in terms of 9/11 is that you certainly see that greater exposure to 9/11. Certainly if you lost a family member or you were actually in the towers or right around the towers. It was more likely to be associated with post-traumatic stress disorders so again greater exposure linked to greater PTSD as well as other outcomes as well. I think that there’s been work published in terms of behavioral health outcomes in terms of substance use but keep in mind that it’s very different.

The impact of a terrorist event and the impact of a natural disaster are obviously very different in nature and that’s one of the reasons why I think the CDC and other organizations were supporting this research because not much is known about the impact of natural disasters in this region in particular. We can certainly draw some guidance from 9/11 research as well as other research and we really based our measurement of hurricane exposure on the Hurricane Katrina scales. But it’s different in some ways and similar in some. I don’t know if Dr. Gwynn if you have anything to add.

Charon Gwynn:

No. I think that’s a very nice summary.

Jamar:

Yes. Thank you for that answer.

Coordinator:

Again if you’d like to ask a question please press star 1 on your touch tone phone.

Loretta Jackson Brown:

Presenters, when I look at the vulnerability factors that you presented, I understand, its common a prior history of mental health, yeah, but the other vulnerability factors are a little benign. What can clinicians do with that information as they’re providing care to their particular population and prepare them for the potential mental health effects from a natural disaster?

Charon Gwynn:

This is Dr. Gwynn. In terms of the populations that are most vulnerable I think one clinician can be sure that the patients who may be older, who may not, be able to have access to evacuate have some evacuation plan or a family member that can check on them.

I think certainly we’d want to make sure that anyone who has a pre-existing mental health condition has the support systems that they need in place and certainly that they’re aware of resources like lifeline that are available to them in the event of emergency. So I think preparation of those who are especially vulnerable during these times I think is probably one way the physicians can reach out and prepare.

Loretta Jackson Brown:

Thank you Dr. Gwynn. Operator do we have any questions?

Coordinator:

At this time I’m showing no further questions.

Loretta Jackson Brown:

And I want to remind the audience they can also submit a written question through the webinar system. I do have one more discussion point for today’s presenter and that is Dr. Schwartz you mentioned about the particular area of New York not necessarily anticipating this type of natural disaster. How prepared was New York for dealing with the mental health needs of the population? We saw the numbers but was the emergency preparedness and readiness piece there? Particularly we were looking at an all hazard response to emergency.

Rebecca Schwartz:

That’s a broad question. It’s hard to say. I think in a lot of ways we weren’t very prepared I think because we hadn’t faced something along these lines in the past. It wasn’t clear exactly the impact that the hurricane was going to have even on the actual physical locality of mental health service providers.

There’s people that do a lot of work in the Rockaway, an area that was very hard hit that Dr. Gwynn mentioned. A lot of providers had to actually close their doors including large mental health clinics and hospitals. So the provision was down I think that there wasn’t a contingency plan in place. The other thing that we’re seeing now two years out from the hurricane is just persistent.

We actually - I didn’t mention this but we did control for a time since the hurricane and even when considering times since the hurricane entered our analyses these mental health impacts are big and persistent over time. And I think that now clinicians are starting to really gear up and realize that just because it’s been a few years it doesn’t mean the people who were hardest hit aren’t still really suffering in terms of mental health because of the impact of property, the impact to employment, that really has very long term effects many years after the winds die down.

I think that the mental health providers in the area are really still trying to grapple with how to handle that and it’s coming at a time where a lot of the service - the grants to provide additional services have ended. There was a fantastic program through visiting our service of New York that many people utilized where social workers and psychologists were really going out into the hardest hit areas and providing free of service trauma focused therapy for three months at individual’s homes or wherever they wanted to meet with them. That grant ended last year.

As we know Project HOPE ended a couple years ago. So there’s been a lot of increased need even now this many years post hurricane that I think everybody’s still realizing and having a hard time providing for.

Loretta Jackson Brown:

Thank you so much for that response. We do have two questions in the webinar system and I’ll point this one to you Dr. Gwynn because I did see where you mentioned substance abuse in your presentation. So this participant is interested in hearing about what percentage of substance abuse relapse would you estimate as not accounted for.

Charon Gwynn:

So that - we haven’t exactly addressed that question and I don’t know if we can look at that with the data that we have. We do know that during times of distress that substance use is - does increase and may increase and - but we did show through the LifeNet calls which I didn’t show here, I apologize. I did show that. Five percent of the callers were calling for substance abuse reasons.

About 30% of those actually didn’t have care for that so we know that people are going with - are experiencing substance abuse issues during the hurricane and that they don’t exactly have someone that they could reach out to. And so - I also can tell you that most of that was alcohol related substance use. So it’s definitely a very real issue.

I think we could explore the extent of relapse. It’s possible that we might be able to look at LifeNet calls to do that. That’s definitely a good question and I think that’s something we could try to explore through some of these I guess more administrative data sets that we have.

Loretta Jackson Brown:

Thank you so much. Operator do we have any on the phone?

Coordinator:

Yes we have one question. (Ashley Ghaffarzadeh) you may go ahead.

Ashley Ghaffarzadeh:

Yes thank you. Thank you both for presenting today and my question is what’s being done differently now in the efforts or maybe organizations that have raised up since this? What has been learned from Hurricane Sandy and mental health?

Rebecca Schwartz:

I’m sorry. What new organizations have emerged as a result or just - Just what’s learned in general

Ashley Ghaffarzadeh:

Yes. What efforts that have maybe have started ever since this was learned?

Charon Gwynn:

This is Dr. Gwynn. I can start - try to say what we’re doing from the perspective of New York City and then I don’t know Dr. Schwartz if you have anything to add.

I did briefly mention that we are enhancing our citywide canvassing effort to - that’d go door to door in the event of an emergency to try to assess the critical needs of the populations that have been impacted. We’re in the process of training our staff and piloting that program so that in the event of emergency we can reach the people who in the areas that are hardest hit and try to assess their needs and link them to services that they may need. I think this came about as a result of Sandy and being able to reach the population that were hardest hit.

And then we also continue to build our public awareness campaigns around hurricanes and disasters. I mentioned we have a website that’s searchable by different threats to New York City including Sandy and other - someone asked about terrorism so all the different emergency responses. And we continue to add to that based on what we learn so - and certainly the impacts of mental health - disasters on mental health is integrated into those materials.

Rebecca Schwartz:

In addition in Long Island I know there has been a lot of discussion. I’ve presented at many different mental health agencies as well as different organizations that represent various vulnerable populations such as seniors and people with substance abuse issues. I think people, the providers as well as the administrators, are taking the information regarding the impact of a vulnerable population and then trying to disseminate it to their constituents and to the people who utilize their clinics in terms of both preparedness and also in terms of helping and deal with current symptom.

In addition part of a project that I’ve become involved with, we’re in the Rockaway and we actually used funding to provide linkages of care among people in that area that was very hard hit. If somebody’s interested and they have higher levels of different symptoms depending on the mental health category we offer linkages of care and we also offer to utilize the funding to cover any uncovered mental health care cost that they may encounter such as co-pays or barriers to care or transportation or child care.

In addition we’ve been in touch with a lot of other organizations that are grassroots that have developed as a result of the hurricane that really encompass lots of different members of the community both from a government side and politicians to various - to community members that - and I’ve seen that a lot in the Rockaway as well in other areas particularly in the south shore in Long Island that have really become very active in helping their neighbors and formulating ideas and plans should there be future disasters particularly with a focus on mental health.

Loretta Jackson Brown:

Thank you so much presenters. Operator we have time for one more question if we have one on

the phone.

Coordinator:

At this time I’m showing no further questions.

Loretta Jackson Brown:

We have one through the webinar and that participant was interested in learning about how our

investigators differentiated stress and anxiety.

Rebecca Schwartz:

In terms of our project we had - stress and anxiety go hand in hand. I’ll start off by saying that. We had two very different measures though. Our perceived stress scale is just a measure of general perceived stress. I don’t have it in front of me to give examples whereas our anxiety measures gives a clinical criteria that mental health providers use to actually diagnose anxiety - generalized anxiety disorders. So stress with lower level and more general whereas anxiety was more diagnostically focused and specific to anxiety symptoms as defined by the DSM-IV, DSM-V which is what mental health providers use to come up with diagnoses.

Loretta Jackson Brown:

Thank you so much. On behalf of COCA I would like to thank everyone for joining us today with a special thank you to our presenters Dr. Schwartz and Dr. Gwynn. We invite you to communicate to our presenters after the webinar.

If you have additional questions for today’s presenters please email us at coca@cdc.gov . Put September 17 COCA call as the subject line of your email and we’ll ensure that your question is forwarded to the presenter for a response. Again the email address is C-O-C-A at cdc.gov.

The recording of this call and the transcript will be posted to the COCA website at emergency.cdc.gov/coca within the next few days. Free continued education is available for this call. Those who participated in today’s COCA call and would like to receive continued education should complete the online evaluation by October 16, 2015. Use course code WC2286.

For those who will complete the online evaluation between October 17, 2015 and September 16, 2016 use course code WZ2286. All continued education credits and contact hours for COCA conference calls are issued online through TCE online, the CDC training and continuing education online system.

To receive information on upcoming COCA calls subscribe to COCA by sending an email to COCA at cdc.gov and write subscribe in the subject line.

Join COCA for two upcoming COCA calls. Next Thursday, September 24 at 2:00 pm Eastern Time we’ll host a call titled The Role of Clinicians and Addressing the Opioid Overdose Epidemic. During this COCA call participants will learn about the drivers of the increase in opioid related morbidity and mortality and steps clinicians can take to reverse the concerning trend. On Thursday October 1 at 2:00 pm Eastern Time we’ll host a call titled How to Prevent and Control Pediatric Influenza. During this COCA call public matter experts will discuss strategies that providers can use to improve influenza prevention and control in children at highest risk, get detailed information about both calls within the COCA webpage at emergency.cdc.gov/coca.

Also CDC launched a face to face for health partners. Like our page at Facebook.com/cdchealthpartnersoutreach to receive COCA updates. Thank you again for being a part of today’s COCA call. Have a great day.

Coordinator:

Thank you and thank you for participating in today’s conference call. You may go ahead and disconnect at this time.

END