Impact of Hurricane Katrina on Gulf Coast veterans with and

without pre-existing mental illness:

South Central MIRECC Hurricane Study

Joseph Constans, Ph.D.South Central MIRECC

May 15, 2007

Schizophrenic

2 : contradictory or antagonistic qualities or attitudes <both parties…have exhibited

schizophrenia over the desired outcome — Elizabeth Drew>

SchizophrenicSchizophrenic

22 :: split personality  split personality

Impact of Hurricane Katrina on Gulf Coast veterans with and

without pre-existing mental illness:

South Central MIRECC Hurricane Study

Joseph Constans, Ph.D.South Central MIRECC

May 15, 2007

Survey Research:Survey Research:

Navigating VA Data Security and Navigating VA Data Security and Privacy DirectivesPrivacy Directives

Joseph Constans, Ph.D.Joseph Constans, Ph.D.South Central MIRECCSouth Central MIRECC

May 15, 2007May 15, 2007

Impact of Hurricane Katrina on Gulf Coast veterans with and

without pre-existing mental illness.• Principal Investigator: Joseph Constans, Ph.D.

• Co-Investigators: Greer Sullivan, M.D. Jennifer Vasterling, Ph.D.

• Project Director: Elizabeth Deitch, Ph.D.

• VA Database managers:Teresa Hudson, PharmDMark Austen

• Survey Development and Administration Consultant: Dana Perry, M.S.

Hurricane Katrina

• The costliest & the most destructive hurricane .

• Massive size devastated Gulf Coast up to 100 miles from center.

• Over half of New Orleans flooded.

• Mississippi coastal communities were wiped out.

• Over 1700 deaths due to storm / its aftermath.

Impact of Natural Disasterson Health

Increased general distress• Lasting >30 months

Increased incidence of psychiatric disturbance• PTSD (31%)• Depression (30%)• GAD (11%)• Panic disorder (10%)

– Hurricane Andrew estimates (Davis et al., 1996)

Poorer physical health outcomes• Lower immune function• Impaired sleep

Risk factors for Poor Health Outcomes

External Factors (outside of individual)

Severity of natural disaster• Similar to relationship between combat / emotional disorders• Severe disasters = more psychopathology

Loss of property / resources

Poor social support• Primary moderator of negative mental health

outcomes

Risk factors for Poor Health Outcomes

“Internal” Factors (characteristics of the individual)

Demographic characteristics• Gender• Ethnic minority status• Lower SES

Pre-existing mental illness• Mostly using retrospective assessment• Prospective studies emphasized depression• Role of PTSD / Schizophrenia ????• Unclear how PMI interacts with other risk factors

Cognitive appraisal style• Beliefs about meaning of the trauma

Hurricane Katrina Risk Factors:Immediate Stressors

• Fear for life of self & others From storm itself, floodwaters, hunger, thirst

• Fear of crime and violence Looting, assaults, breakdowns of civil authority

• Breakdown of civil authority

• Exposure to bodies / potential contaminates

• Uncertainty & Ambiguity N.O. evacuation stretched to a month; status of homes, jobs,

friends/family/pets uncertain.

• Loss of housing Temporary housing in trailers Permanent move

• Loss of employment / income

• Loss of belongings Furniture, photographs, sentimental items

Hurricane Katrina Risk Factors:Prolonged Stressors

• Families separated

• Loss of neighbors

• Loss of church organization

• Changes in family structures Increased divorce, marriage, births

Hurricane Katrina Risk Factors:Disruption of Social Networks

• Loss of housing Temporary housing in trailers Permanent move

• Loss of employment / income

• Loss of belongings Furniture, photographs, sentimental items

Hurricane Katrina Risk Factors:Demographic Characteristics

Reactions to Katrina:Empirical Studies to Date

Kessler, Galea, Jones, & Parker (2006)• Use of cell phones for contacting residents

– Cell phone numbers obtained from service organization

• Access to mental disorder incidence prior to storm– From NCS-R

• Documented increases in mental disorders– PTSD, depression most common– Frequency of disorders doubled

• Found suicidal ideation did not increase proportionately

• Beliefs in post traumatic growth important moderator

Challenges

• Diaspora

Door-to-door interviews strategy - impossible• Hurricane Andrew studies

Changes in contact information

Those experiencing greatest loss / trauma may be the most likely to have moved.

VA opportunities

• Contact information At time of storm Updated since Katrina??

• Prescription• Health care• Benefits

• Veteran population

• Prospective data Mental illness diagnoses Medical conditions

Examining impact of Katrina on Gulf Coast veterans

What is the health impact on veterans?• Veterans have not been specifically studied.• It is unclear how veterans, especially those with combat stress,

will react to disasters.

What is the specific impact on veterans with psychiatric disturbances such as PTSD/ schizophrenia?

• Use of VA databases to identify +/- for pre-existing mental illness

• Allows for a prospective assessment• Allows to assess possibly unique features of PTSD /

schizophrenia

Examine fit of current risk models• Does psychiatric status impact other risk factors?

Study Aim #1

• How does pre-storm psychiatric status impact post-disaster health functioning:

Additional negative mental health outcomes

Physical health status

General functioning

Study Aim #2

• How does pre-storm psychiatric status impact known predictors, mediators, and moderators of post-disaster health outcomes?

Increased exposure to trauma

Lower post-disaster social support

Pathological cognitive styles• Increased negative appraisals• Decrease belief in growth potential

Decreased capacity for associated with negative mental health outcomes

Study Aim #3

• Are models used to predict post-disaster negative health outcomes comparable for those with and without mental illness?

Test separate models for those with and without pre-storm mental illness

Overview of Study Design

• Telephone survey experiences during & after Katrina Loss, social support, cognitive factors Current health / mental health functioning

• Administered by professional survey firm.

• 500 participants 250 with pre-existing mental illness 250 with no PMI.

Participants• 500 male veterans

• Age 18-60 as of 8/29/05

• Received services at N.O. or Biloxi VAMC

• Resided in affected area at time of Katrina: LA parishes: Jefferson, Orleans, Plaquemines, St.

Tammany, St. Bernard MS counties: Hancock, Harrison, Jackson Further restricted by zip codes within parish/county to

increase probability of direct exposure to hurricane stress.

ParticipantsGrouping variable: Pre-storm mental illness

• MI positive cohort (n=250) 2+ visits to mental health clinic between 8/1/04-8/1/05 Diagnosis of depression, PTSD, or psychotic disorder

• MI negative cohort (n=250) 2+ visits to primary care clinic between 8/1/04-8/1/05 No mental illness diagnoses

Survey MeasuresMeasuring “internal” characteristics - prestorm

• Demographic Information Age, sex, ethnicity, marital status, education

• Military History Service branch, combat zone experience

• Traumatic life events Checklist of lifetime traumatic events other than Katrina (e.g., serious

accident, assault). Modified version of Diagnostic Interview Schedule (CDC, 1989)

Measuring “internal” characteristics – post storm

• Cognitive appraisal style Posttraumatic Cognitions Inventory (Foa, Clark, Tolin & Orsillo, 1999) Posttraumatic growth (Kessler, Galea et al., 2006)

Survey Measures (cont’d)Measuring external factors

• Katrina trauma severity Emotional events experienced (e.g., witnessing deaths, loss of

friends/family/pets in storm Other traumas during storm & aftermath (e.g., assault, robbery)

• Loss - Household Information Living situation pre-K and now (location, structure, household

members); extent of damage to home/possessions

• Loss - Employment/Income Status at time of Katrina, current status, changes

• Social Support Actual changes in family, neighborhood, and friendship networks. Perceived social support.

Survey Measures (cont’d)

Health Outcomes

• Post-traumatic stress disorder Short PTSD Rating Interview (SPRINT; Connor & Davidson, 2001)

• Depression 9-item screen from Patient Health Questionnaire (PHQ-2; Kroenke ,

Spitzer & Williams, 2003)

• Panic disorder PD screen from Brief Patient Health Questionaire (Spitzer, Kroenke

& Williams, 1999)

• Generalized Anxiety Disorder GAD-7 (Spitzer, Kroenke, Williams, & Lowe, 2006) assesses

frequency of anxiety symptoms

Survey Measures (cont’d)Health Outcomes

• Anger Anger subscale of the Buss-Perry Aggression scale (Buss & Perry,

1992)

• Alcohol Use 3 items from Alcohol Use Disorders Identification Test (Babor, de la

Fuente, Saunders & Grant,1989) Also, compare consumption pre- & post-Katrina

• Physical Health 9-item checklist for specific health problems (e.g., diabetes, cancer) 16-item measure for respondent evaluation of state of health; some

original items and some from SF-12 Health Survey (Ware, Kosinski & Keller, 1996)

Procedure: Participant Identification

• Using info from VA data warehouse 250 MI+ veterans will be randomly selected.

• PTSD, depression, psychotic disorder

250 MI- veterans

Groups match MI+ cohort on age, ethnicity, zip code at time of Katrina, number of clinic visits.

• Names & contact info supplied to survey administration firm.

Procedure: Contact Protocol

• Pre-notification letter sent to potential participants, allows opt-out

by postcard or phone (wait 3-4 weeks).

• Interviewer call obtain verbal informed consent.

• Survey as telephone interview (about 1 hour long).

• Address recorded $20 compensation check.

Procedure: Follow-Up Location• For veterans

Undeliverable mail Invalid phone numbers……

• Use of locator service (possibly using SSN).

• Second iteration of identification/enrollment: Generate list of names for 120% of remaining

veterans needed to reach n=250 for each group. Follow contact protocol Repeat if necessary

Results

• Overcoming obstacles……….

Data Security IssuesData Security Issues

Stolen laptop with veteran dataStolen laptop with veteran data– Washington, DCWashington, DC– Laptop recovered; no PHI compromisedLaptop recovered; no PHI compromised

Loss of veteran data external storage deviceLoss of veteran data external storage device– Birmingham, ALBirmingham, AL

Security Requirements for VA Security Requirements for VA Research InformationResearch Information

Memorandum: FebruaryMemorandum: February, 2007, 2007

VA research data may not be stored outside VA (unless VA research data may not be stored outside VA (unless applicable permission obtained).applicable permission obtained).

Data transfer to non-VA computer must comply with VA Data transfer to non-VA computer must comply with VA directive 6504.directive 6504.

When VA data is stored on non-VA system, system “must meet When VA data is stored on non-VA system, system “must meet requirements set for in FISMA.”requirements set for in FISMA.”

Research subjects names, addresses, and Social Security Research subjects names, addresses, and Social Security Numbers may be stored only on VA servers. Numbers may be stored only on VA servers.

Challenges: Privacy/Security IssuesChallenges: Privacy/Security IssuesNew VA security directives.New VA security directives.

– Data Security checklistData Security checklistRequired for all research Required for all research

protocolsprotocols

Researchers must indicate Researchers must indicate

compliance with several compliance with several

statements about data securitystatements about data security

Research may only proceed Research may only proceed

without delay if all statements without delay if all statements

can be answered “yes.”can be answered “yes.”

Two statements are particularly Two statements are particularly

problematic for this study problematic for this study →→

Problematic Security Problematic Security Checklist ItemsChecklist Items

““Names, addresses, and Social Security Names, addresses, and Social Security Numbers (real and scrambled) have been Numbers (real and scrambled) have been replaced with a code. replaced with a code. NoteNote: Names, addresses, : Names, addresses, and Social Security Numbers (real or scrambled) and Social Security Numbers (real or scrambled) may only be maintained on a VA server and may only be maintained on a VA server and documentation of the procedure by which the documentation of the procedure by which the data were coded must remain within the VA”data were coded must remain within the VA”

– We cannot answer “yes” to this statement We cannot answer “yes” to this statement →→

Problematic Security Problematic Security Checklist ItemsChecklist Items

Contact info is not useful in coded/scrambled form.Contact info is not useful in coded/scrambled form. we need to actually contact veteranswe need to actually contact veterans

Social Security numbers requiredSocial Security numbers requiredaid in location of displaced individuals.aid in location of displaced individuals.If SSN not used, possible under-representation of those most If SSN not used, possible under-representation of those most disrupted by Katrinadisrupted by Katrina

The info must be removed from VA serversThe info must be removed from VA servers– Survey firm needs to generate letters, contact/callback Survey firm needs to generate letters, contact/callback

protocols & incentive checks.protocols & incentive checks.– Need to use info for location servicesNeed to use info for location services– Need to interface with proprietary CATI softwareNeed to interface with proprietary CATI software

Problematic Security Problematic Security Checklist ItemsChecklist Items

““For data that will reside on a non-VA For data that will reside on a non-VA server: The server has to be certified and server: The server has to be certified and accredited as required by Federal accredited as required by Federal Information and Security Management Act Information and Security Management Act of 2002 (FISMA). of 2002 (FISMA). NotNote: your facilities ISO e: your facilities ISO should be consulted.”should be consulted.”

– We cannot answer “yes” to this item either We cannot answer “yes” to this item either →→

Problematic Security Problematic Security Checklist ItemsChecklist Items

Survey administration firm, SRBI, has Survey administration firm, SRBI, has provided extensive data security protocol, provided extensive data security protocol, and certifies that they meet the standards and certifies that they meet the standards set forth in FISMA.set forth in FISMA.However, they are not officially FISMA However, they are not officially FISMA accredited.accredited.FISMA accreditation would take at least a FISMA accreditation would take at least a year, and SRBI maintains it would cost year, and SRBI maintains it would cost more than all their VA contracts combined.more than all their VA contracts combined.

Unclear ProceduresUnclear ProceduresDirectives are vague at this point regarding what Directives are vague at this point regarding what can be done if items must be answered “no”:can be done if items must be answered “no”:– Checklist states: “Checklist states: “If you answer NO to any one of the If you answer NO to any one of the

statements, you may not remove or transmit the data statements, you may not remove or transmit the data outside the VA and you must consult with your outside the VA and you must consult with your supervisor, ISO and Privacy Officer.”supervisor, ISO and Privacy Officer.”

Can supervisor, ISO & Privacy Officer approve an Can supervisor, ISO & Privacy Officer approve an exception to checklist elements?exception to checklist elements?– Meaning of “consult” is unknownMeaning of “consult” is unknown– No clear placement of responsibility for No clear placement of responsibility for

approval/exception.approval/exception.– No forms exist for approval/exceptionNo forms exist for approval/exception

Unclear Procedures (cont)Unclear Procedures (cont)National Procedures also vagueNational Procedures also vague– No clear written information about how to obtain No clear written information about how to obtain

names, addresses and phone numbers. names, addresses and phone numbers. Web site and other instructional materials only address Web site and other instructional materials only address SSNSSN

PlanPlan for Action for Action

South Central MIRECC Hurricane Study:

A Metaphor for the Rebuilding of New Orleans?

• Takes longer than expected Systems become dysfunctional

• IRB

• Personnel

PI becomes dysfunctional?

• Hurdles will emerge.

• We will ultimately succeed!