60,000 disaster victims speak: Part II. Summary and implications of the disaster mental health research

Predicting PTSD using the New York Risk Score with genotype data: potential clinical and research opportunities

BACKGROUND

We previously developed a post-traumatic stress disorder (PTSD) screening instrument, ie, the New York PTSD Risk Score (NYPRS), that was effective in predicting PTSD. In the present study, we assessed a version of this risk score that also included genetic information.

METHODS

Utilizing diagnostic testing methods, we hierarchically examined different prediction variables identified in previous NYPRS research, including genetic risk-allele information, to assess lifetime and current PTSD status among a population of trauma-exposed adults.

RESULTS

We found that, in predicting lifetime PTSD, the area under the receiver operating characteristic curve (AUC) for the Primary Care PTSD Screen alone was 0.865. When we added psychosocial predictors from the original NYPRS to the model, including depression, sleep disturbance, and a measure of health care access, the AUC increased to 0.902, which was a significant improvement (P = 0.0021). When genetic information was added in the form of a count of PTSD risk alleles located within FKBP5, COMT, CHRNA5, and CRHR1 genetic loci (coded 0-6), the AUC increased to 0.920, which was also a significant improvement (P = 0.0178). The results for current PTSD were similar. In the final model for current PTSD with the psychosocial risk factors included, genotype resulted in a prediction weight of 17 for each risk allele present, indicating that a person with six risk alleles or more would receive a PTSD risk score of 17 × 6 = 102, the highest risk score for any of the predictors studied.

CONCLUSION

Genetic information added to the NYPRS helped improve the accuracy of prediction results for a screening instrument that already had high AUC test results. This improvement was achieved by increasing PTSD prediction specificity. Further research validation is advised.

Mitigating flood exposure: Reducing disaster risk and trauma signature

Introduction. In 2011, following heavy winter snowfall, two cities bordering two rivers in North Dakota, USA faced major flood threats. Flooding was foreseeable and predictable although the extent of risk was uncertain. One community, Fargo, situated in a shallow river basin, successfully mitigated and prevented flooding. For the other community, Minot, located in a deep river valley, prevention was not possible and downtown businesses and one-quarter of the homes were inundated, in the city's worst flood on record. We aimed at contrasting the respective hazards, vulnerabilities, stressors, psychological risk factors, psychosocial consequences, and disaster risk reduction strategies under conditions where flood prevention was, and was not, possible. Methods. We applied the "trauma signature analysis" (TSIG) approach to compare the hazard profiles, identify salient disaster stressors, document the key components of disaster risk reduction response, and examine indicators of community resilience. Results. Two demographically-comparable communities, Fargo and Minot, faced challenging river flood threats and exhibited effective coordination across community sectors. We examined the implementation of disaster risk reduction strategies in situations where coordinated citizen action was able to prevent disaster impact (hazard avoidance) compared to the more common scenario when unpreventable disaster strikes, causing destruction, harm, and distress. Across a range of indicators, it is clear that successful mitigation diminishes both physical and psychological impact, thereby reducing the trauma signature of the event. Conclusion. In contrast to experience of historic flooding in Minot, the city of Fargo succeeded in reducing the trauma signature by way of reducing risk through mitigation.

The New York PTSD risk score for assessment of psychological trauma: male and female versions

We previously developed a new posttraumatic stress disorder (PTSD) screening instrument-the New York PTSD Risk Score (NYPRS). Since research suggests different PTSD risk factors and outcomes for men and women, in the current study we assessed the suitability of male and female versions of this screening instrument among 3298 adults exposed to traumatic events. Using diagnostic test methods, including receiver operating characteristic (ROC) curve and bootstrap techniques, we examined different prediction domains, including core PTSD symptoms, trauma exposures, sleep disturbances, depression symptoms, and other measures to assess PTSD prediction models for men and women. While the original NYPRS worked well in predicting PTSD, significant interaction was detected by gender, suggesting that separate models are warranted for men and women. Model comparisons suggested that while the overall results appeared robust, prediction results differed by gender. For example, for women, core PTSD symptoms contributed more to the prediction score than for men. For men, depression symptoms, sleep disturbance, and trauma exposure contributed more to the prediction score. Men also had higher cut-off scores for PTSD compared to women. There were other gender-specific differences as well. The NYPRS is a screener that appears to be effective in predicting PTSD status among at-risk populations. However, consistent with other medical research, this instrument appears to require male and female versions to be the most effective.

The effect of Hurricane Katrina on the prevalence of health impairments and disability among adults in New Orleans: differences by age, race, and sex

We examined the effects of Hurricane Katrina on disability-related measures of health among adults from New Orleans, U.S.A., in the year after the hurricane, with a focus on differences by age, race, and sex. Our analysis used data from the American Community Survey to compare disability rates between the pre-Katrina population of New Orleans with the same population in the year after Katrina (individuals were interviewed for the study even if they relocated away from the city). The comparability between the pre- and post-Katrina samples was enhanced by using propensity weights. We found a significant decline in health for the adult population from New Orleans in the year after the hurricane, with the disability rate rising from 20.6% to 24.6%. This increase in disability reflected a large rise in mental impairments and, to a lesser extent, in physical impairments. These increases were, in turn, concentrated among young and middle-aged black females. Stress-related factors likely explain why young and middle-aged black women experienced worse health outcomes, including living in dwellings and communities that suffered the most damage from the hurricane, household breakup, adverse outcomes for their children, and higher susceptibility.

Use of a web portal for support and research after a disaster: opportunities and lessons learned

Background

In this report we describe the development and use of a web portal in the aftermath of the 2004 tsunami. This large scale disaster confronted many displaced people with death, despair and need for information and support. Awareness and insight in the emotional impact of disasters can provide opportunities for surveillance and early treatment. Moreover, online support systems can contribute to community building, empowerment of victims and resilience.

Objective

We evaluate the development and use of a multilingual web portal that combined a platform for information, emotional support, self assessment and referral with research opportunities. The rapid development, use, advantages, difficulties and learning points are discussed.

Methods

A multidisciplinary working group from the University Medical Centre Utrecht, the Major Incident Hospital and the Central Military Hospital developed a web portal for tsunami victims. The webportal combined: (1) a forum aimed at community building, (2) self assessment tools that in the same time function as a reseach survey, (3) e-consultation, and (4) an information portal.

Results

Within 3 weeks after the tsunami, the working group launched an open, online service (www.TISEI.org. Tsunami Intrenational Survey on Emotional Impact) to foster community) support in the aftermath of the disaster. It combined four functionalities that were earlier previously only used separately. The portal had over 36.800 unique visitors in the first two years. At least 31% (144/464) percent of the Dutch surviving victims could be reached for a survey through the site. The TISEI-environment was available in 15 languages and visitors came from all over the world. Ninety-five percent of all visitors came from Europe or the United States. Subsequent to immediate disaster support, the web portal also served as a memorial archive for anniversary meetings and follow-up incentives. Difficulties we experienced were lack of funding, time pressure, victim-anonymisation, international collaboration and long term maintenance.

Conclusions

A multilingual website with combined modalities for emotional care and research after a natural disaster proved feasible. Web based services like www.TISEI.org in the aftermath of mass disasters can help community building and deliver low level, patient centred and easily accessible information and care. A multilingual website with combined modalities for emotional care and research after a natural disaster proved feasible. Growing Internet penetration world wide and especially the rapid expansion and influence of online communities enables delivery of care and perform research with the internetInternet as a platform. The unpredictable nature of disaster does put time pressure on the development of online solutions and influenced the yield of our site. This highlights the necessity of developing methods and (inter) national collaborations in advance, secure funding, and learn from earlier initiatives.

Is T.V. traumatic for all youths? The role of preexisting posttraumatic-stress symptoms in the link between disaster coverage and stress

In youths, watching T.V. coverage of a disaster is associated with traumatic-stress symptoms. However, the role of predisaster symptoms in this link has not been addressed. In this study, urban-school youths who had experienced both Hurricanes Katrina and Gustav (N = 141; grades 4-8) were assessed 12 months and 6 months before Gustav and then 1 month after Gustav. The amount of T.V. viewing was associated with post-Gustav stress symptoms, controlling for pre-Gustav symptoms. However, pre-Gustav stress symptoms interacted with T.V. viewing in predicting post-Gustav symptoms such that for youths with higher preexisting symptoms, there was a stronger association between T.V. viewing and level of post-Gustav symptoms. The results advance the literature on the role of media coverage in stress reactions by showing that preexisting symptoms can be an important component of identifying which children are likely to be most negatively affected by TV coverage.

Framework for research on children's reactions to disasters and terrorist events

Clinical work and research relative to child mental health during and following disaster are especially challenging due to the complex child maturational processes and family and social contexts of children's lives. The effects of disasters and terrorist events on children and adolescents necessitate diligent and responsible preparation and implementation of research endeavors. Disasters present numerous practical and methodological barriers that may influence the selection of participants, timing of assessments, and constructs being investigated. This article describes an efficient approach to guide both novice and experienced researchers as they prepare to conduct disaster research involving children. The approach is based on five fundamental research questions: "Why?, Who?, When?, What?, and How?" Addressing each of the "four Ws" will assist researchers in determining "How" to construct and implement a study from start to finish. A simple diagram of the five questions guides the reader through the components involved in studying children's reactions to disasters. The use of this approach is illustrated with examples from disaster mental health studies in children, thus simultaneously providing a review of the literature.

Traumatic grief and traumatic stress in survivors 12 years after the genocide in Rwanda

The relationship between exposure to traumatic events and traumatic grief and the role of mediating and moderating variables [peritraumatic distress, post traumatic stress disorder (PTSD) symptoms and symptoms of depression] were studied in survivors of the genocide of Batutsi in Rwanda in 1994. One hundred and two survivors (70 women, mean age 45 ± 7.53 years) participated in this retrospective study. All of them had lost a member of their family. The severity of traumatic exposure (Comprehensive Trauma Inventory), peritraumatic distress (Peritraumatic Distress Inventory), current PTSD symptoms (PTSD Checklist), depressive symptoms (Beck Depression Inventory) and traumatic grief symptoms (Inventory of Traumatic Grief) was evaluated. A hierarchical multiple regression analysis was then conducted to examine the relative contribution of each variable to the symptoms of traumatic grief. The severity of traumatic exposure was related to traumatic grief symptoms (B=0.06, R=0.6, R(2) =0.36 and ß=0.6, t=7.54, p=0.00). The Baron and Kenny procedure (1986) (including three separate regressions), along with the Sobel test, was used to test mediation effects. Peritraumatic distress and PTSD symptoms may be mediating variables between traumatic exposure and traumatic grief. Traumatic grief is a complex but assessable entity, where previous distress and suffering result from both psychological trauma and the loss of a loved one.

The impact of the Great East Japan earthquake on mandatory psychiatric emergency hospitalizations in Tokyo: a retrospective observational study

On 11 March 2011, the eastern part of Japan was struck by a magnitude 9.0 quake. About 20 000 people were killed or were missing, and a nuclear crisis followed. In Tokyo, people were indirectly exposed to the earthquake and nuclear crisis by TV broadcast. The aim of our study was to evaluate the potential effect of the series of catastrophes on psychiatric emergency hospitalizations in Tokyo. Clinical records of patients who were mandatorily admitted to Tokyo Metropolitan Matsuzawa Hospital by law because of urgent risk to self or others were reviewed. Records regarding the 2 years of investigation, which include the 6 months after the earthquake, were reviewed. The six months after the earthquake were compared with the eighteen months before the earthquake in clinical and demographic data using independent t-tests or χ(2) tests. During the 6 months before and after the earthquake, 97 and 127 people were mandatorily admitted. χ(2) Tests demonstrated a significant increase in the number of patients after the earthquake (P = 0.045), attributable to the significant increase in the number of patients with schizophrenia after the earthquake (P = 0.011, 32 vs 56), whereas there were no significant differences in the number of patients with other diagnoses between those two periods. Independent t-tests revealed that patients admitted after the earthquake had marginally significantly shorter periods of education compared with those admitted before the earthquake (13.78 vs 12.82 years, P = 0.084). This work suggests that patients with schizophrenia were more sensitive to indirect exposure to the earthquake and that a shorter period of education was a potential risk factor.

Community destruction and traumatic stress in post-tsunami Indonesia

How are individuals affected when the communities they live in change for the worse? This question is central to understanding neighborhood effects, but few study designs generate estimates that can be interpreted causally. We address issues of inference through a natural experiment, examining post-traumatic stress at multiple time points in a population differentially exposed to the 2004 Indian Ocean tsunami. The data, from the Study of the Tsunami Aftermath and Recovery, include interviews with over 16,000 Indonesian adults before and after the event. These data are combined with satellite imagery, direct observation, and informant interviews to examine the consequences of community destruction for post-traumatic stress. Using multilevel linear mixed models, we show that community destruction worsens post-traumatic stress, net of rigorous controls for individual experiences of trauma and loss. Furthermore, the effect of community destruction persists over time and extends across a wide range of community types.

Examining a comprehensive model of disaster-related posttraumatic stress disorder in systematically studied survivors of 10 disasters

OBJECTIVES

Using a comprehensive disaster model, we examined predictors of posttraumatic stress disorder (PTSD) in combined data from 10 different disasters.

METHODS

The combined sample included data from 811 directly exposed survivors of 10 disasters between 1987 and 1995. We used consistent methods across all 10 disaster samples, including full diagnostic assessment.

RESULTS

In multivariate analyses, predictors of PTSD were female gender, younger age, Hispanic ethnicity, less education, ever-married status, predisaster psychopathology, disaster injury, and witnessing injury or death; exposure through death or injury to friends or family members and witnessing the disaster aftermath did not confer additional PTSD risk. Intentionally caused disasters associated with PTSD in bivariate analysis did not independently predict PTSD in multivariate analysis. Avoidance and numbing symptoms represented a PTSD marker.

CONCLUSIONS

Despite confirming some previous research findings, we found no associations between PTSD and disaster typology. Prospective research is needed to determine whether early avoidance and numbing symptoms identify individuals likely to develop PTSD later. Our findings may help identify at-risk populations for treatment research.

Relationships between impact on employment, working conditions, socio-occupational categories and symptoms of post-traumatic stress disorder after the industrial disaster in Toulouse, France

OBJECTIVES

The aims of this paper were (1) to analyze the prevalence of symptoms of post-traumatic stress disorder (S-PTSD) in a population of workers 1 year after an industrial disaster; and (2) to assess the role of factors of vulnerability such as the occupational impact of a disaster and economic conditions.

METHODS

A cross-sectional survey assessing the relationships between socio-occupational category, impact on employment and S-PTSD was conducted by the self-administered impact of event scale-revised.

RESULTS

The prevalence of S-PTSD in workers in the peripheral zone (<3 km around the explosion site) was 12% in men and 18% in women. Factors significantly associated with S-PTSD in men were non-managerial socio-occupational category: employees (ORa = 4.3; [2.3; 7.8]), factory workers/laborers (ORa = 3.7; [1.8; 7.6]), intermediate professions (ORa = 3.3; [1.9; 5.9]), and artisans (ORa = 3; [1.3; 7.7]); and layoff (ORa = 2.6; [1.5; 4.5]) or unusable workplace after the explosion (ORa = 1.8; [1.1; 2.8]). In women, factors significantly associated with S-PTSD were the socio-occupational categories of employees and factory workers (ORa = 2.2; [1.4; 3.5]), artisans (ORa = 2.7; [1.3; 5.7]) and intermediate professions, (ORa = 1.5; [1; 2.3]) and reporting of an occupational accident (ORa = 1.5; [1.1; 2.2]).

CONCLUSION

Impact on the workplace and socioeconomic conditions were associated with S-PTSD. The epidemiological approach in disaster situations needs to be improved, particularly in the social and occupational dimension when economically active populations are involved. Vulnerable subgroups, defined by occupational impact and low socioeconomic category, should be taken into account.

Psychological Consequences of Indirect Exposure to Disaster Due to the Haiti Earthquake

Introduction

Few studies have focused on the mental health consequences of indirect exposure to disasters caused by naturally occurring hazards. The present study assessed indirect exposure to the 2010 earthquake in Haiti among Haitian-Americans now living in Miami; these subjects had no direct exposure to the earthquake, but retained their cultural identity, language, and connection to family and friends in Haiti.

Methods

Two months following the earthquake a sample of Haitian-Americans was surveyed inquiring about: (1) their psychological reactions to the quake; (2) types of exposures experienced by their family members and friends in Haiti; and (3) symptom levels of (a) major depression, (b) generalized anxiety disorder, (c) complicated grief, (d) mental health status, and (e) physical health status.

Results

Haitian-Americans living in Miami experienced a broad spectrum of indirect exposures to the 2010 earthquake in Haiti. These exposures were strongly associated with psychological distress, trauma-related mental health consequences, and diminished health status. Most notable was the multiplicity of indirect exposures to the on-scene experiences of multiple family members and friends in Haiti.

Conclusions

Consideration should be given to the psychological impact and needs for support among indirectly-exposed populations with strong affiliation to directly-impacted victims.

Shultz JM, Besser A, Kelly F, Allen A, Schmitz S, Hausmann V, Marcelin LH, Neria Y. Psychological consequences of indirect exposure to disaster due to the Haiti earthquake.Prehosp Disaster Med.2012;27(4):1-10.

The Spectrum of Human Reactions to Terrorist Attacks with Weapons of Mass Destruction: Early Management Considerations

Residents of a community who are intentionally exposed to a hazardous biological, chemical, or radiological agent (including medical first-responders and other civil defense personnel who live in that community) will exhibit a spectrum of psychological reactions that will impact the management of the incident. These reactions will range from a variety of behaviors of normal people under abnormal circumstances that either will help or hinder efforts to contain the threatening agent, deliver medical care, and reduce the morbidity, mortality, and costs associated with the disaster, to the development of new, or exacerbation of preexisting, mental disorders.

Anticipating the decisions that people will make and actions they will take as the crisis develops is hindered by the limited number of previous disasters that bear crucial similarities to a terrorist attack with a weapon of mass destruction. Such actions, therefore, could serve as models to predict community reactions. One result of a study that attempted to fill in these gaps suggested that medical first-responders and their spouses/significant others may require separately crafted information and advice to reduce the potential for disharmony within the family that could affect job performance during the crisis.

For those persons who exhibit emotional lability or cognitive deficits, evaluation of their psychiatric signs and symptoms may be more difficult than imagined, especially with exposure to nerve agents. Appreciation of these difficulties, and possession of the skill to sort through them, will be required of those assigned to triage stations. The allocation and utilization of mental health resources as the incident unfolds will be the responsibility of local consequence managers; these managers should be aware of the results of a recently-held workshop that attempted to reach consensus among experts in disaster mental health, based on the peer-reviewed literature, on the efficacy and safety of various approaches to early psychological interventions for victims of mass trauma and disasters.

Thus, psychological factors are likely to be significant in the management of a terrorist incident that involves an agent of mass destruction. Emergency medical workers with managerial responsibilities, whether limited in scope or community-wide, should be aware of these factors, and should train to handle them through effective risk communication as part of their planning and preparation.

When Disaster Strikes: Responding to the Needs of Children

When a disaster strikes, parents are quick to seek out the medical advice and reassurance of their primary care physician, pediatrician, or in the case of an emergency, an emergency department physician. As physicians often are the first line of responders following a disaster, it is important that they have a thorough understanding of children's responses to trauma and disaster and of recommended practices for screening and intervention. In collaboration with mental health professionals, the needs of children and families can be addressed. Policy-makers and systems of care hold great responsibility for resource allocation, and also are well-placed to understand the impact of trauma and disaster on children and children's unique needs in such situations.

Resilience in the face of disaster: prevalence and longitudinal course of mental disorders following hurricane Ike

Objectives

Natural disasters may increase risk for a broad range of psychiatric disorders, both in the short- and in the medium-term. We sought to determine the prevalence and longitudinal course of posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), panic disorder (PD), depression, and suicidality in the first 18 months after Hurricane Ike.

Methods

Six hundred fifty-eight adults representative of Galveston and Chambers Counties, Texas participated in a random, population-based survey. The initial assessment was conducted 2 to 5 months after Hurricane Ike struck Galveston Bay on September 13, 2008. Follow-up assessments were conducted at 5 to 9 and 14 to 18 months after Hurricane Ike.

Results

Past-month prevalence of any mental disorder (20.6% to 10.9%) and hurricane-related PTSD (6.9% to 2.5%) decreased over time. Past-month prevalence of PTSD related to a non-disaster traumatic event (5.8% to 7.1%), GAD (3.1% to 1.8%), PD (0.8% to 0.7%), depression (5.0% to 5.6%), and suicidality (2.6% to 4.2%) remained relatively stable over time.

Conclusions

PTSD, both due to the hurricane and due to other traumatic events, was the most prevalent psychiatric disorder 2 to 5 months after Hurricane Ike. Prevalence of psychiatric disorders declined rapidly over time, suggesting that the vast majority of individuals exposed to this natural disaster ‘bounced back’ and were resilient to long-term mental health consequences of this large-scale traumatic event.

National telemental health responses to a major bushfire disaster

In response to the Victorian bushfire disaster in 2009, various telemental health services were provided by three national agencies: Kids Helpline (BoysTown), MensLine Australia (Crisis Support Services) and Lifeline Australia. All provider agencies used their existing national service structures and staff resources, which were expanded to respond to bushfire-related service demand. We examined service provider reports and conducted key informant interviews. Despite a lack of quantitative data on consumer outcomes and perspectives, it appears that all three telemental health services experienced significant increases in overall service uptake levels in the wake of the bushfires. Uptake of specialized telephone-, web-, email- and crisis counselling services was substantial, although that of callback services was very limited. Potential clients encountered specific barriers in relation to service access and the callback model. The bushfire experience highlighted the impact of transitory living circumstances and the increased complexity of post-disaster calls on service provision. Telemental health services need to be integrated into mainstream services and disaster response structures.

Relations between Loss of Services and Psychiatric Symptoms in Urban and Non-Urban Settings following a Natural Disaster

Disasters have been associated with both acute and prolonged distress and significant post-disaster psychiatric symptoms. These outcomes may be further complicated by extended periods without vital services and supplies, such as electricity and drinking water. The present study investigated the relations between post-disaster loss of services and psychiatric symptoms in urban/non-urban disaster victims. Random-digit-dial methodology was used to interview 1,249 victims of Hurricane Ike, a strong storm that hit Galveston, TX in 2008. Findings demonstrated significant relations between loss of services and post-disaster symptoms of posttraumatic stress disorder (PTSD), depression, and worry. These relations varied by urban/non-urban settings; there were significant positive relations between loss of services and symptoms of depression in non-urban settings, but not in urban settings. Similarly, a stronger relation between loss of services and symptoms of PTSD also was demonstrated in non-urban compared to urban settings. Findings highlight the potential importance of pre-disaster preparation, post-disaster restoration of services, and post-disaster community support in post-disaster psychiatric outcomes, with a particular emphasis in non-urban settings.

Posttraumatic stress disorder, depression, and perceived needs for psychological care in older persons affected by Hurricane Ike

OBJECTIVE

To examine the prevalence and correlates of disaster-related posttraumatic stress disorder (PTSD), depression, and needs for psychological care in older persons affected by Hurricane Ike.

METHOD

A total of 193 adults aged 60 or older who resided in the Galveston Bay area were interviewed 2-5 months following Hurricane Ike. Pre-, peri-, and post-disaster variables hypothesized to be related to PTSD and depressive symptoms, and perceived needs for psychological care were assessed.

RESULTS

Weighted prevalences of past-month Ike-related PTSD and depression were 7.6% and 8.6%, respectively. Risk factors for Ike-related PTSD symptoms were predominantly peri-disaster in nature, with greater hurricane exposure, and peri-event dissociative and autonomic activation symptoms associated positively with these symptoms. Risk factors for depressive symptoms were predominantly pre-disaster in nature, with being married/living with partner associated negatively, and prior disaster exposure and pre-disaster PTSD or depression associated positively with these symptoms. 27.2% of the sample endorsed at least one of the perceived needs for psychological care assessed. A history of PTSD or depression, greater peri-event autonomic activation, and Ike-related PTSD and depressive symptoms were associated with greater need for psychological care.

LIMITATIONS

This study is limited by its cross-sectional design and employment of psychiatric screening instruments.

CONCLUSIONS

A substantial proportion of older adults may have PTSD and depression, as well as perceived needs for psychological care, after a disaster. Assessment of disaster exposures, and peri-event dissociative and autonomic symptoms may help identify older adults at risk for disaster-related psychopathology. Older adults with a history of PTSD or depression, and greater peri-event autonomic activation and PTSD symptoms may be more likely to have needs for psychological care.

A prospective study of religiousness and psychological distress among female survivors of Hurricanes Katrina and Rita

This prospective study examined the pathways by which religious involvement affected the post-disaster psychological functioning of women who survived Hurricanes Katrina and Rita. The participants were 386 low-income, predominantly Black, single mothers. The women were enrolled in the study before the hurricane, providing a rare opportunity to document changes in mental health from before to after the storm, and to assess the protective role of religious involvement over time. Results of structural equation modeling indicated that, controlling for level of exposure to the hurricanes, pre-disaster physical health, age, and number of children, pre-disaster religiousness predicted higher levels of post-disaster (1) social resources and (2) optimism and sense of purpose. The latter, but not the former, was associated with better post-disaster psychological outcome. Mediation analysis confirmed the mediating role of optimism and sense of purpose.

Reducing the Risk of Posttraumatic Stress Disorder in Children Following Natural Disasters

A significant number of children suffer long-term psychological disturbance following exposure to a natural disaster. Evidence suggests that a dose-response relationship exists, so that children and adolescents who experience the most intense or extensive exposure to the risk factors for posttraumatic stress disorder (PTSD) are likely to develop the most serious and persistent symptoms. Risk factors include gender, age, personality, extent of exposure to the natural disaster, amount of damage to property and infrastructure, witnessing the death or injury of others or perceiving a threat to one's own life. Knowing these factors enables various strategies to be put in place to decrease the risk of psychological disturbance following traumatic events. Reestablishing a sense of safety, security and normality is important in the aftermath of a natural disaster, and promoting social connectedness, positive family functioning and effective coping mechanisms can make children more resilient in the face of catastrophic events. This paper examines the risk and protective factors associated with the development of PTSD, and considers how schools can use this knowledge to contribute to the recovery effort and reduce the prevalence of PTSD among pupils in the wake of a natural disaster.

Cognitive and psychological reactions of the general population three months after the 2011 Tohoku earthquake and tsunami

Background

The largest earthquake on record in Japan (magnitude 9.0) occurred on March 11, 2011, and the subsequent tsunami devastated the Pacific coast of Northern Japan. These further triggered the Fukushima I nuclear power plant accidents. Such a hugely complex disaster inevitably has negative psychological effects on general populations as well as on the direct victims. While previous disaster studies enrolled descriptive approaches focusing on direct victims, the structure of the psychological adjustment process of people from the general population has remained uncertain. The current study attempted to establish a path model that sufficiently reflects the early psychological adaptation process of the general population to large-scale natural disasters.

Methods and Findings

Participants from the primary disaster area (n = 1083) and other areas (n = 2372) voluntarily participated in an online questionnaire study. By constructing path models using a structural equation model procedure (SEM), we examined the structural relationship among psychological constructs known related to disasters. As post-traumatic stress symptoms (PTS) were significantly more present in people in the primarily affected area than in those in secondary- or non-affected areas, the path models were constructed for the primary victims. The parsimoniously depicted model with the best fit was achieved for the psychological-adjustment centered model with quality of life (QoL) as a final outcome.

Conclusion

The paths to QoL via negative routes (from negative cognitive appraisal, PTS, and general stress) were dominant, suggesting the importance of clinical intervention for reducing negative cognitive appraisal, and for caring for general stress and PTS to maintain QoL at an early stage of psychological adaptation to a disaster. The model also depicted the presence of a positive route where positive cognitive appraisal facilitates post-traumatic growth (PTG) to achieve a higher QoL, suggesting the potential importance of positive psychological preventive care for unexpected natural disasters.

Psychological support and recovery in the aftermath of natural disaster

Natural disasters can result in a range of mental health outcomes among the affected population. Appropriate mental health interventions are required to promote recovery. In the aftermath of the 2009 bushfires in Victoria, Australia, a collaboration of trauma experts, the Australian and Victorian state governments and health professional associations developed an evidence-informed three-level framework outlining recommended levels of care. The framework was underpinned by an education and training agenda for mental health professionals. This framework has been successfully applied after further natural disasters in Australia. This paper outlines the steps included in each of the levels.

A conceptual framework for understanding the mental health impacts of oil spills: lessons from the Exxon Valdez oil spill

This paper introduces a conceptual framework for understanding and responding to the currently unfolding social and psychological impacts of the Deepwater Horizon oil spill. Drawing from the concept of corrosive communities and its relationship to theories of conservation of resources, cognitive activation, and risk and resilience, the conceptual model identifies three levels or tiers of impacts: biopsychosocial impacts that are direct consequences of the contamination of the physical environment; interpersonal impacts that are direct consequences of the biopsychosocial impacts; and intrapersonal or psychological impacts that are consequences of both the biopsychosocial and the interpersonal impacts. The model is then evaluated in light of research conducted in the aftermath of the Exxon Valdez oil spill as well as studies of other manmade disasters, and offers a set of testable hypotheses that predict likely impacts of the Deepwater Horizon oil spill. The conceptual framework may be used to identify strategies to develop community resilience and target specific services to prevent and mitigate these adverse effects.

Randomized controlled trial of an internet-based intervention using random-digit-dial recruitment: the Disaster Recovery Web project

Disasters occur with high frequency throughout the world and increase risk for development of mental health problems in affected populations. Research focused on the development and evaluation of secondary prevention interventions addressing post-disaster mental health has high potential public-health impact. Toward this end, internet-based interventions (IBIs) are particularly attractive in that they: (1) offer a low-cost means of delivering standardized, targeted, personalized intervention content to a broad audience; and (2) are easily integrated within a stepped care approach to screening and service delivery. We describe a unique study design intended to evaluate an IBI with a disaster-affected population-based sample. Description and rationale are provided for sampling selection and procedures, selection of assessment measures and methods, design of the intervention, and statistical evaluation of critical outcomes. Unique features of this intervention include the use of a population-based sample, telephone and internet-based assessments, and development of a highly individualized web-based intervention. Challenges related to the development and large-scale evaluation of IBIs targeting post-disaster mental health problems, as well as implications for future research and practice are discussed.

Nonuse and dropout attrition for a web-based mental health intervention delivered in a post-disaster context

Web-based mental health interventions are an excellent means to provide low cost, easily accessible care to disaster-affected populations shortly after exposure to an event. However, the extent that individuals will access and use such interventions is largely unknown. We examined predictors of nonuse and dropout attrition for a web-based mental health intervention in 1,249 randomly selected adults in two Texas counties--Galveston and Chambers--that were hardest hit by Hurricane Ike in 2008. Participants completed a structured telephone interview to assess demographics, impact of disaster exposure, history of traumatic events, mental health symptoms, and service utilization. Following the interview, participants were oriented and invited to access a web-based intervention and then contacted four months later to evaluate their use of the website and mental health functioning. Separate logistic and Poisson regressions were used to determine baseline predictors of nonuse attrition, predictors of dropout attrition, and predictors of completing intervention modules. Results suggested that the strongest buffer against nonuse attrition and dropout attrition was having considered seeking formal mental health treatment. Results of this study inform the development and dissemination of web-based interventions in future disaster affected areas.

Combined prolonged exposure therapy and paroxetine for PTSD related to the World Trade Center attack: a randomized controlled trial

OBJECTIVE

Selective serotonin reuptake inhibitors (SSRIs) are often recommended in combination with established cognitive-behavioral therapies (CBTs) for posttraumatic stress disorder (PTSD), but combined initial treatment of PTSD has not been studied under controlled conditions. There are also few studies of either SSRIs or CBT in treating PTSD related to terrorism. The authors compared prolonged exposure therapy (a CBT) plus paroxetine (an SSRI) with prolonged exposure plus placebo in the treatment of terrorism-related PTSD.

METHOD

Adult survivors of the World Trade Center attack of September 11, 2001, with PTSD were randomly assigned to 10 weeks of treatment with prolonged exposure (10 sessions) plus paroxetine (N=19) or prolonged exposure plus placebo (N=18). After week 10, patients discontinued prolonged exposure and were offered 12 additional weeks of continued randomized treatment.

RESULTS

Patients treated with prolonged exposure plus paroxetine experienced significantly greater improvement in PTSD symptoms (incidence rate ratio=0.50, 95% CI=0.30-0.85) and remission status (odds ratio=12.6, 95% CI=1.23-129) during 10 weeks of combined treatment than patients treated with prolonged exposure plus placebo. Response rate and quality of life were also significantly more improved with combined treatment. The subset of patients who continued randomized treatment for 12 additional weeks showed no group differences.

CONCLUSIONS

Initial treatment with paroxetine plus prolonged exposure was more efficacious than prolonged exposure plus placebo for PTSD related to the World Trade Center attack. Combined treatment medication and prolonged exposure therapy deserves further study in larger samples with diverse forms of PTSD and over longer follow-up periods.

Temperamental Traits and Severity of PTSD Symptoms

The paper presents the results of a longitudinal study of two groups of participants of motor vehicle accidents (MVA). They were investigated twice: The first time after 1–6 months (N = 362) or 12–24 months (N = 337) after a MVA, and then 1 year after the initial assessment. We assumed that, among the environmental variables (severity of experienced trauma, trauma-related prolonged stressors, other traumatic event and social support), two temperamental traits, emotional reactivity and briskness, would be factors influencing the severity of posttraumatic stress disorder. We also assumed that, after a longer distance from the MVA, temperament would be affected by symptoms of PTSD. Analysis of the cross-lagged effects confirmed the expectations regarding the “temperamental vulnerability” to PTSD in the shorter timespan after the MVA, indicating the process of “complication” and leading to changes in temperament under the influence of the disorder. Moreover, emotional reactivity was associated concurrently with higher levels of PTSD symptoms, especially in interaction with the severity of experienced trauma. Emotional reactivity and briskness also predicted changes in symptom severity, after controlling for the initial PTSD level and especially in interaction with trauma-related prolonged stressors. We propose implications of the results in our understanding “enduring personality change after catastrophic experience” as a diagnostic category in the ICD-10 and underline the significance of temperament as a factor influencing individual “vulnerability” to trauma.

Posttraumatic stress disorder following the September 11, 2001, terrorist attacks: a review of the literature among highly exposed populations

The September 11, 2001 (9/11), terrorist attacks were unprecedented in their magnitude and aftermath. In the wake of the attacks, researchers reported a wide range of mental and physical health outcomes, with posttraumatic stress disorder (PTSD) the one most commonly studied. In this review, we aim to assess the evidence about PTSD among highly exposed populations in the first 10 years after the 9/11 attacks. We performed a systematic review. Eligible studies included original reports based on the full Diagnostic and Statistical Manual of Mental Disorders (4th ed., rev.; American Psychiatric Association, 2000) criteria of PTSD among highly exposed populations such as those living or working within close proximity to the World Trade Center (WTC) and the Pentagon in New York City and Washington, DC, respectively, and first responders, including rescue, cleaning, and recovery workers. The large body of research conducted after the 9/11 attacks in the past decade suggests that the burden of PTSD among persons with high exposure to 9/11 was substantial. PTSD that was 9/11-related was associated with a wide range of correlates, including sociodemographic and background factors, event exposure characteristics, loss of life of significant others, and social support factors. Few studies used longitudinal study design or clinical assessments, and no studies reported findings beyond six years post-9/11, thus hindering documentation of the long-term course of confirmed PTSD. Future directions for research are discussed.

Like a fish out of water: reconsidering disaster recovery and the role of place and social capital in community disaster resilience

In this paper we draw on the findings of a critical, multi-sited ethnographic study of two rural communities affected by a wildfire in British Columbia, Canada to examine the salience of place, identity, and social capital to the disaster recovery process and community disaster resilience. We argue that a reconfiguration of disaster recovery is required that more meaningfully considers the role of place in the disaster recovery process and opens up the space for a more reflective and intentional consideration of the disorientation and disruption associated with disasters and our organized response to that disorientation. We describe a social-psychological process, reorientation, in which affected individuals and communities navigate the psychological, social and emotional responses to the symbolic and material changes to social and geographic place that result from the fire's destruction. The reorientation process emphasizes the critical importance of place not only as an orienting framework in recovery but also as the ground upon which social capital and community disaster resilience are built. This approach to understanding and responding to the disorientation of disasters has implications for community psychologists and other service providers engaged in supporting disaster survivors. This includes the need to consider the complex dynamic of contextual and cultural factors that influence the disaster recovery process.

The “Trauma Signature:” Understanding the Psychological Consequences of the 2010 Haiti Earthquake

The 2010 Haiti earthquake was one of the most catastrophic episodes in history, leaving 5% of the nation’s population killed or injured, and 19% internally displaced. The distinctive combination of earthquake hazards and vulnerabilities, extreme loss of life, and paralyzing damage to infrastructure, predicts population-wide psychological distress, debilitating psychopathology, and pervasive traumatic grief. However, mental health was not referenced in the national recovery plan. The limited MHPSS services provided in the first eight months generally lacked coordination and empirical basis.

There is a need to customize and coordinate disaster mental health assessments, interventions, and prevention efforts around the novel stressors and consequences of each traumatic event. An analysis of the key features of the 2010 Haiti earthquake was conducted, defining its “Trauma Signature” based on a synthesis of early disaster situation reports to identify the unique assortment of risk factors for post-disaster mental health consequences. This assessment suggests that multiple psychological risk factors were prominent features of the earthquake in Haiti. For rapid-onset disasters, Trauma Signature (TSIG) analysis can be performed during the post-impact/pre-deployment phase to target the MHPSS response in a manner that is evidence-based and tailored to the event-specific exposures and experiences of disaster survivors. Formalization of tools to perform TSIG analysis is needed to enhance the timeliness and accuracy of these assessments and to extend this approach to human-generated disasters and humanitarian crises.

Five years later: recovery from post traumatic stress and psychological distress among low-income mothers affected by Hurricane Katrina

Hurricane Katrina, which struck the Gulf Coast of the United States in August 2005, exposed area residents to trauma and extensive property loss. However, little is known about the long-run effects of the hurricane on the mental health of those who were exposed. This study documents long-run changes in mental health among a particularly vulnerable group-low income mothers-from before to after the hurricane, and identifies factors that are associated with different recovery trajectories. Longitudinal surveys of 532 low-income mothers from New Orleans were conducted approximately one year before, 7-19 months after, and 43-54 months after Hurricane Katrina. The surveys collected information on mental health, social support, earnings and hurricane experiences. We document changes in post-traumatic stress symptoms (PTSS), as measured by the Impact of Event Scale-Revised, and symptoms of psychological distress (PD), as measured by the K6 scale. We find that although PTSS has declined over time after the hurricane, it remained high 43-54 months later. PD also declined, but did not return to pre-hurricane levels. At both time periods, psychological distress before the hurricane, hurricane-related home damage, and exposure to traumatic events were associated with PTSS that co-occurred with PD. Hurricane-related home damage and traumatic events were associated with PTSS without PD. Home damage was an especially important predictor of chronic PTSS, with and without PD. Most hurricane stressors did not have strong associations with PD alone over the short or long run. Over the long run, higher earnings were protective against PD, and greater social support was protective against PTSS. These results indicate that mental health problems, particularly PTSS alone or in co-occurrence with PD, among Hurricane Katrina survivors remain a concern, especially for those who experienced hurricane-related trauma and had poor mental health or low socioeconomic status before the hurricane.

Critical biological pathways for chronic psychosocial stress and research opportunities to advance the consideration of stress in chemical risk assessment

Emerging evidence suggests that psychosocial stress and toxicants may interact to modify health risks. Stress-toxicant interactions could be important in chemical risk assessment, but these interactions are poorly understood and additional research is necessary to advance their application. Environmental health research can increase knowledge of these interactions by exploring hypotheses on allostatic load, which measures the cumulative impacts of stress across multiple physiological pathways, using knowledge about physiological pathways for stress-related health effects, and evidence of common target pathways for both stress and toxicants. In this article, critical physiological pathways for stress-related health effects are discussed, with specific attention to allostatic load and stress-toxicant interactions, concluding with research suggestions for potential applications of such research in chemical risk assessment.

Shared traumatic stress and the long-term impact of 9/11 on Manhattan clinicians

A sample of 481 social workers from Manhattan participated in a study of the impact of the September 11, 2001 (9/11) World Trade Center (WTC) attacks. A variety of risk factors associated with posttraumatic stress and secondary trauma were examined in relation to shared traumatic stress (STS), a supraordinate construct reflecting the dual nature of exposure to traumatic events. Risk factors included attachment style, exposure to potentially traumatic life events, and enduring distress attributed to the WTC attacks. It was expected that clinicians' resilience would mediate the relationship between these risk factors and STS. Using path analytic modeling, the findings support the study's hypotheses that insecure attachment, greater exposure to potentially traumatic life events in general, and the events of 9/11 in particular are predictive of higher levels of STS. Contrary to expectation, enduring distress attributed to 9/11 was not associated with resilience. Resilience, however, was found to be a mediator of the relationships between insecure attachment, exposure to potentially traumatic life events, and STS but did not mediate the relationship between enduring distress attributed to 9/11 and STS. Implications for theory, research, and practice are discussed.

Child development in the context of disaster, war, and terrorism: pathways of risk and resilience

This review highlights progress over the past decade in research on the effects of mass trauma experiences on children and youth, focusing on natural disasters, war, and terrorism. Conceptual advances are reviewed in terms of prevailing risk and resilience frameworks that guide basic and translational research. Recent evidence on common components of these models is evaluated, including dose effects, mediators and moderators, and the individual or contextual differences that predict risk or resilience. New research horizons with profound implications for health and well-being are discussed, particularly in relation to plausible models for biological embedding of extreme stress. Strong consistencies are noted in this literature, suggesting guidelines for disaster preparedness and response. At the same time, there is a notable shortage of evidence on effective interventions for child and youth victims. Practical and theory-informative research on strategies to protect children and youth victims and promote their resilience is a global priority.

Physical symptoms 14 months after a natural disaster in individuals with or without injury are associated with different types of exposure

OBJECTIVE

To investigate whether different types of exposure to the 2004 tsunami were associated with physical symptoms 14 months after the disaster and to study correlations between survivors' physical and psychological symptoms.

METHODS

Using a cross-sectional design, 1505 survivors from the 2004 Indian Ocean Tsunami, tourists from Stockholm, who had been present in the disaster areas, responded to a postal questionnaire. Eight groups based on type of exposure were created. Physical symptoms occurring on a daily or weekly basis over the past year were investigated in four indices: musculoskeletal, cardiorespiratory, neurological, and gastrointestinal. Mental health symptoms (General Health Questionnaire-12) and posttraumatic stress symptoms (Impact of Event Scale-Revised) were also investigated. Multiple logistic regression analyses were conducted with controls for background variables and exposure, with physical symptoms as outcome variables. The association between physical and psychological symptoms was studied with the Spearman Rank Order Correlation.

RESULTS

Different types of exposure during the disaster were associated with physical symptoms 14 months later for survivors both with and without severe physical injury. The single exposure of life threat, also in combination with other exposures, was associated with a higher risk for reporting of physical symptoms. Physical symptoms showed modest yet significant correlation with psychological symptoms.

CONCLUSION

It is important to pay attention to both physical and psychological symptoms among disaster survivors whether they have been injured or not. A relatively simple questionnaire about physical symptoms may be a good complement to the scales used to assess psychological problems after disaster.

Natural disaster and risk of psychiatric disorders in Puerto Rican children

We examined the persistence of psychiatric disorders at approximately 18 and 30 months after a hurricane among a random sample of the child and adolescent population (4–17 years) of Puerto Rico. Data were obtained from caretaker-child dyads (N = 1,886) through in person interviews with primary caretakers (all children) and youth (11–17 years) using the Diagnostic Interview Schedule for Children IV in Spanish. Logistic regressions, controlling for sociodemographic variables, were used to study the relation between disaster exposure and internalizing, externalizing, or any disorder. Children’s disaster-related distress manifested as internalizing disorders, rather than as externalizing disorders at 18 months post-disaster. At 30 months, there was no longer a significant difference in rates of disorder between hurricane-exposed and non-exposed youth. Results were similar across age ranges. Rates of specific internalizing disorders between exposed and unexposed children are provided. Research and clinical implications are discussed.

Community stress, psychosocial hazards, and EPA decision-making in communities impacted by chronic technological disasters

Psychosocial stress has emerged as an important consideration in managing environmental health risks. Stress has adverse impacts on health and may interact with environmental hazards to increase health risk. This article's primary objective was to explore psychosocial stress related to environmental contamination. We hypothesized that knowledge about stress should be used in conjunction with chemical risk assessment to inform environmental risk management decisions. Knowledge of psychosocial stress at contaminated sites began by exploring the relationships among social capital, collective efficacy, and contamination at the community level. We discussed stress at the family and individual levels, focusing on stress proliferation, available resources, and coping styles and mechanisms. We then made recommendations on how to improve the use of information on psychosocial stress in environmental decision-making, particularly in communities facing chronic technological disasters.

Complicated grief associated with hurricane Katrina

BACKGROUND

Although losses are important consequences of disasters, few epidemiological studies of disasters have assessed complicated grief (CG) and none assessed CG associated with losses other than death of loved one.

METHODS

Data come from the baseline survey of the Hurricane Katrina Community Advisory Group, a representative sample of 3,088 residents of the areas directly affected by Hurricane Katrina. A brief screen for CG was included containing four items consistent with the proposed DSM-V criteria for a diagnosis of bereavement-related adjustment disorder.

RESULTS

Fifty-eight and half percent of respondents reported a significant hurricane-related loss: Most-severe losses were 29.0% tangible, 9.5% interpersonal, 8.1% intangible, 4.2% work/financial, and 3.7% death of loved one. Twenty-six point one percent respondents with significant loss had possible CG and 7.0% moderate-to-severe CG. Death of loved one was associated with the highest conditional probability of moderate-to-severe CG (18.5%, compared to 1.1-10.5% conditional probabilities for other losses), but accounted for only 16.5% of moderate-to-severe CG due to its comparatively low prevalence. Most moderate-to-severe CG was due to tangible (52.9%) or interpersonal (24.0%) losses. Significant predictors of CG were mostly unique to either bereavement (racial-ethnic minority status, social support) or other losses (prehurricane history of psychopathology, social competence.).

CONCLUSIONS

Nonbereavement losses accounted for the vast majority of hurricane-related possible CG despite risk of CG being much higher in response to bereavement than to other losses. This result argues for expansion of research on CG beyond bereavement and alerts clinicians to the need to address postdisaster grief associated with a wide range of losses.

Social capital and post-disaster mental health

BACKGROUND

Despite national and international policies to develop social capital in disaster-affected communities, empiric evidence on the association between social capital and disaster mental health is limited and ambiguous.

OBJECTIVE

The study explores the relationship between social capital and disaster mental health outcomes (PTSD, anxiety, and depression) in combination with individual factors (appraisal, coping behavior, and social support).

DESIGN

This is a community-based cross-sectional study in a flood-affected town in northern England. The study is part of the MICRODIS multi-country research project that examines the impact of natural disasters. It included 232 flood-affected respondents.

RESULTS

The findings showed that a considerable part of the association between cognitive and structural social capital and mental health is exerted through individual appraisal processes (i.e. property loss, primary and secondary appraisal), social support, and coping behavior. These individual factors were contingent on social capital. After the inclusion of individual characteristics, cognitive social capital was negatively related to lower mental health problems and structural social capital was positively associated to experiencing anxiety but not to PTSD or depression. Depression and anxiety showed a different pattern of association with both components of social capital.

CONCLUSIONS

Individual oriented stress reducing interventions that use appraisal processes, social support, and coping as starting points could be more effective by taking into account the subjective experience of the social context in terms of trust and feelings of mutual support and reciprocity in a community. Findings indicate that affected people may especially benefit from a combination of individual stress reducing interventions and psychosocial interventions that foster cognitive social capital.

The early psychological impacts of the Deepwater Horizon oil spill on Florida and Alabama communities

BACKGROUND

Although public concern has focused on the environmental impact of the Deepwater Horizon oil spill, the public health impact on a broad range of coastal communities is minimally known.

OBJECTIVE

We sought to determine the acute level of distress (depression, anxiety), mechanisms of adjustment (coping, resilience), and perceived risk in a community indirectly impacted by the oil spill and to identify the extent to which economic loss may explain these factors.

METHODS

Using a community-based participatory model, we performed standardized assessments of psychological distress (mood, anxiety), coping, resilience, neurocognition, and perceived risk on residents of fishing communities who were indirectly impacted (n = 71, Franklin County, Florida) or directly exposed (n = 23, Baldwin County, Alabama) to coastal oil. We also compared findings for participants who reported income stability (n = 47) versus spill-related income loss (n = 47).

RESULTS

We found no significant differences between community groups in terms of psychological distress, adjustment, neurocognition, or environmental worry. Residents of both communities displayed clinically significant depression and anxiety. Relative to those with stable incomes, participants with spill-related income loss had significantly worse scores on tension/anxiety, depression, fatigue, confusion, and total mood disturbance scales; had higher rates of depression; were less resilient; and were more likely to use behavioral disengagement as a coping strategy.

CONCLUSIONS

Current estimates of human health impacts associated with the oil spill may underestimate the psychological impact in Gulf Coast communities that did not experience direct exposure to oil. Income loss after the spill may have a greater psychological health impact than the presence of oil on the immediately adjacent shoreline.