Impact of Hurricane Katrina on Gulf Coast veterans with and without preexisting mental illness.

1
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, PharmD
• James S. Williams
• Survey Development and Administration Consultant
  
  
• Dana Perry, M.S.

2
Hurricane Katrina

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

3
Hurricane Katrina

• One of the costliest and most destructive
  hurricanes in U.S. history.

Gulfport, MS
4
Hurricane Katrina

• Over half of New Orleans flooded when levees
  breached.

5
Hurricane Katrina

• Approximately 1720 people died in storm and
  aftermath.
  

6
Psychological Stressors of Hurricane Katrina

• Fear for life of self others
• From storm itself, floodwaters, hunger, thirst
• Fear of crime and violence
• Looting, assaults, breakdowns of civil authority
• Loss of belongings
• Basic necessities, sentimental items
• Loss of support system
• Neighborhoods families split up in evacuation
  or rescue
  
• Uncertainty Ambiguity
• N.O. evacuation stretched to a month status of
  homes, jobs, friends/family/pets uncertain.

7
Impact of Natural Disasterson Health

• Review of research shows disasters lead to
• Increased general distress
• Increased incidence of psychiatric disturbance
• Poorer physical health outcomes
• (Norris, Friedman Watson, 2002)
• Most common psychiatric illnesses after disaster
  PTSD, generalized anxiety disorder, major
  depression, panic disorder
  
• (David, et al., 1996)

8
Current Study Aims

• Study Aim 1 To determine whether veterans with a
  psychiatric disorder prior to Hurricane Katrina
  are at increased risk of additional negative
  mental health outcomes
• Pre-existing mental illness (PMI) is a risk
  factor for developing new-onset disorders after
  natural disaster (Norris Elrod, 2006).
  
• Veterans have not been specifically studied.
• It is unclear how veterans, especially those with
  combat stress, will react to disasters.

9
Current Study Aims

• Study Aim 2 To determine whether individuals
  with pre-Katrina mental illness have fewer social
  support resources and appraise their response to
  the hurricane and its aftermath more negatively
  than veterans without PMI.
• Lack of social support negative cognitive
  appraisals are additional risk factors for
  post-disaster mental illness (see review by
  Norris et al, 2002)
• PMI may be associated with these risk factors,
  contributing to negative outcomes.

10
Current Study Aims

• Study Aim 3 To examine the relative impact of
  various risk factors and determine if predictors
  of post-disaster health outcomes are similar for
  veterans with and without PMI.
• Exploratory. Predictors of interest include
• Demographic race, education
• Financial resources
• Severity of exposure to hurricane stressors
  (location on day of Katrina, damage to property,
  traumatic events)
  
• Reactions to hurricane stressors (emotions
  experienced, changes in how one views the world
  and other people)
  
• Social support
• Cognitive appraisals

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

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Participants

• 500 male veterans aged 18-60 as of 8/29/05
• Received services at N.O. or Biloxi VAMC.
• Resided in affected area at time of Katrina
• LA parishes Jefferson, Orleans, Plaquemines, St.
  Tammany, St. Bernard
  
• MS counties Hancock, Harrison, Jackson
• MI positive cohort (n250)
• 1 visits to mental health clinic between
  8/1/04-8/1/05
  
• Diagnosis of depression, PTSD, or psychotic
  disorder
  
• MI negative cohort (n250)
• 1 visits to primary care clinic between
  8/1/04-8/1/05
  
• No mental illness diagnoses

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• Geographic Eligibility
• Participants with pre-Katrina residence in a zip
  code at least 50 in one of the following
  
• Orleans Parish
• Jefferson Parish
• Plaquemines Parish
• St. Tammany Parish
• St. Bernard Parish
• Hancock County
• Harrison County
• Jackson County

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Survey Measures

• Demographic information
• Employment
• Income
• Military history
• Household information
• Katrina traumatic events
• Damage to property
• Feelings during Katrina
• Changes in worldview

• Hope for future
• Cognitive appraisals
• Perceived social support
• Post-traumatic stress disorder
• Generalized anxiety disorder
• Panic disorder
• Depression

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Preliminary Results

• 352 interviews completed
• 168 MI
• 184 MI with the following pre-Katrina
  diagnoses
  
• 108 (58.7) PTSD
• 71 (39.7) Depression
• 1 (0.5) Panic
• 7 (3.8) GAD
• 11 (6.0) Bipolar
• 15 (4.3) Schizophrenia

16
Demographics

• Mean age 53.7, median 57
• MI group slightly younger (mean age52.2, vs. 55
  for MI)
  
• Race 42 Black, 50 White, 8 Other/Mixed (no
  difference between groups)
  
• 66 married or living with someone as if married
  (no difference between groups)
  
• Education
• 96 graduated from high school
• 67 have vocational education or some college
  21 have college degrees
  
• 7 have advanced degrees
• (no difference between groups)

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Demographics

• Income
• Pre-Katrina, median category 30,000 - 34,999
• (no difference between groups)
• Post-Katrina, median category 25,000 - 29,999
  
  
• (no difference between groups)
• Employment significant difference between
  groups
  
• 41 of MI group, 66 of MI- group employed
  pre-Katrina
  
• 35 of MI group, 62 of MI- group employed
  currently
  
• 45 individuals (21 MI and 24 MI-) report having
  lost a job since Katrina. However, most have
  found other jobs only 18 people who were
  employed pre-Katrina are unemployed now. Eight
  respondents who were not employed pre-Katrina are
  working currently.
• 26 respondents said they make less money now than
  before Katrina, but 20 reported they earn more at
  their job currently.

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Military History

• Branch of service
• 47 Army 20 Navy, 15 marines, 14 Air Forces,
  2 Coast Guard, 2 National Guard
  
• 80 of the Marines are in the MI group.
• Other branches are more evenly distributed
  between the groups.
  
• Combat zone service 74 of MI group and 49 the
  MI group served in a combat zone
  
• Combat Locations
• 68 of Vietnam vets are in the MI group.
• 83 of OIF vets are in MI group.
• Other locations and those in 2 combat zones are
  roughly equal between the groups.
  
• 5 people report serving in 3 combat zones 4 of
  those are in MI group.

19
Geographic Location
20
No group differences in geographic distribution
21
64 remained in area on day of Katrina
22
24 are still living outside the area today
23
Damage Losses

• No differences between groups
• Type of damage
• 97 reported physical damage to structures on the
  property where they lived
  
• 57 reported damage to car, truck or boat
• 84 reported damage to items inside their home
• 68 reported the loss of sentimental items
• Median dollar estimate of total losses 30,000
• Median estimated payments from insurance and
  grants 12,000
  
• 82 reported losses exceeding payments median
  shortfall 10,000

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Traumatic events during Katrina
25
Hypothesis tests

• Hypothesis 1 Veterans with pre-Katrina mental
  disorders will show significantly higher rates of
  new-onset posttraumatic stress disorder (PTSD),
  depression, panic disorder (PD), and generalized
  anxiety disorder (GAD), as compared with veterans
  without evidence of pre-existing mental
  disorders.
• H1 is supported for panic disorder
• New onset PD MI group (n183) 39.3
• MI- group (n168) 8.3
• ?2 45.5, p
• H1 is supported for generalized anxiety disorder
  
  
• New onset GAD MI group (n177) 57.1
• MI- group (n168) 19.6
• ?2 50.8, p

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Hypothesis tests

• It is not clear how new onset PTSD should be
  defined. Items referenced Katrina-related
  trauma, so all Katrina-related PTSD could be
  considered new. Alternatively, only individuals
  without previous PTSD could be considered new.
  H1 is supported with either analysis
• If all considered new
• Current PTSD MI group (n184) 67.9
• MI- group (n168) 25.0
• ?2 64.9, p
• Analyzing only those without PMI PTSD
• New onset PTSD MI group (n76) 57.9
• MI- group (n168) 25.0
• ?2 24.8, p

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Hypothesis tests

• H1 appears supported with regard to depression.
• Examining those with no PMI diagnosis of
  depression
  
• New Depression MI group (n111) 53.2
• MI- group (n168) 13.7
• ?2 50.2, p
• A limitation here a PTSD diagnosis can include
  depression, without a separate explicit
  depression diagnosis being recorded.
  

28
Hypothesis tests

• Hypothesis 2a Veterans with pre-Katrina mental
  illness will report lower levels of social
  support than veterans without pre-Katrina mental
  illness.
• H2a is supported.
• Perceived Social Support (range 1-4)
• MI mean 2.73 (SD .81)
• MI- mean 3.27 (SD .68)
• t 6.75, p

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Hypothesis tests

• Hypothesis 2b Veterans with pre-Katrina mental
  illness will engage in more negative cognitive
  appraisals of the impact of the hurricane and
  their actions and emotions in response to it,
  than will veterans without pre-Katrina mental
  illness.
• H2b is supported.
• Negative Cognitions score (range 1-5)
• MI mean 2.43 (SD 1.12)
• MI- mean 1.55 (SD .70)
• t 8.93, p

30
Mediation?

• Group differences in mental health outcomes may
  be mediated through social support and
  cognitions.
  
• Social support is a resource which may help
  protect against the development of mental
  illness.
  
• Negative cognitive appraisals of oneself and
  ones situation may make the development of new
  mental illness more likely.
  
• Regression analyses using continuous scores on
  outcome measures suggest partial mediation.
  

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• DV Depression score
• Correlations
• 
  Depression Group Soc Sup
  
• Group (MI1, MI-2) -.49
• Social Support -.52 .34
• Negative Cognitions .69 -.42 -.54
• Regression
• Block Predictors ß p ?R2
• 1 PMI diag Depression .176
• 2 Social support -.361
• Negative cognitions .214 .08
• Soc sup X Neg cog .268
• 3 Group -.212
• Total R2 .558
• Remaining partial correlation of Group with
  Depression -.24 (p

32

• DV PTSD score
• Correlations
• PTSD Group Soc Sup
• Group (MI1, MI-2) -.49
• Social Support -.50 .34
• Negative Cognitions .77 -.42 -.54
• Regression
• Block Predictors ß p ?R2
• 1 PMI diagnosisPTSD .094
• 2 Social support -.279
• Negative cognitions .343
• Soc sup X Neg cog .271
• 3 Group -.121
• Total R2 .644
• Remaining partial correlation of Group with PTSD
  -.15 (p

33

• DV Panic Disorder score
• Correlations
• 
  Panic Group Soc Sup
  
• Group (MI1, MI-2) -.43
• Social Support -.42 .34
• Negative Cognitions .58 -.42 -.54
• Regression
• Block Predictors ß p ?R2
• 1 PMI diagnosis PD .008 ns .006
• 2 Social support -.176 .08 .345
• Negative cognitions .336
• Soc sup X Neg cog .079 ns
• 3 Group -.205
• Total R2 .384
• Remaining partial correlation of Group with Panic
  -.23 (p

34

• DV GAD score
• Correlations
• GAD Group Soc
  Sup
  
• Group (MI1, MI-2) -.50
• Social Support -.50 .34
• Negative Cognitions .73 -.42 -.54
• Regression
• Block Predictors ß p ?R2
• 1 PMI diagnosis GAD .033 ns .011
• 2 Social support -.365
• Negative cognitions .190 ns
• Soc sup X Neg cog .356
• 3 Group -.201
• Total R2 .605
• Remaining partial correlation of Group with GAD
  -.27 (p

35
Within-Group Exploratory Analyses

• To examine the relative impact of various risk
  factors and determine whether other predictors of
  post-disaster health outcomes are similar for
  individuals with and without pre-Katrina mental
  disorders.
• For each mental health outcome, several variables
  were assessed as potential predictors in separate
  analyses for the MI group and the MI- group
  
• Which variables were useful predictors did differ
  between the groups.
  
• Due to multicollinearity of some predictors, and
  especially of predictors and associated
  interaction terms, the clearest illustration of
  the relative value of useful predictors emerges
  when the models are reduced only to those
  variables which contribute meaningful variance.

36
Within-Group Exploratory Analyses

• Potential Predictors
• Education
• Income (post-Katrina, showed stronger relations
  with outcomes)
  
• Race AA vs. White/Other (Whites and Other/Mixed
  did not differ on outcomes)
  
• In affected area on day of Katrina
• Katrina Traumatic Events
• Katrina damage items endorsed
• Emotions felt during Katrina
• Hope for future
• Changes in worldview (spirituality, closeness to
  others, trust in others, sense of meaning
  purpose in life)
  
• Social Support
• Negative Cognitions
• Interactions Katrina Trauma x Cognitions, Social
  Support x Cognitions, Katrina Trauma x Social
  Support

37

• DV PTSD Scale Score
• MI
• Predictor ß ?R2 p
• ? Race African-Amer. .118 .036
• ? Katrina trauma .194 .250
• ? Negative cognitions .638 .310
• Total R2 .596
• MI
• Predictor ß ?R2 p
• ? Feelings during Katrina .142 .183
• ? Social support -.176 .080
• ? Negative cognitions .515 .296
• ? Social sup X K. trauma .302 .071
• Total R2 .629

High Trauma
Moderate Trauma
Low Trauma
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• DV Depression Scale Score
• MI
• Predictor ß ?R2 p
• ? In affected area on K-day .164 .030
• ? Social support -.167 .210
• ? Negative cognitions .519 .185
• Total R2 .425
• MI
• Predictor ß ?R2 p
• ? Education -.132 .063
• ? Income -.124 .073
• ? Worldview change -.134 .061
• ? Negative cognitions .836 .283
• ? Social sup X Cognitions -.382 .025
• ? Social sup X K. trauma .164 .019
• Total R2 .530

39

• DV Depression Scale Score
• MI Group

40

• DV Panic Disorder Scale Score
• MI
• Predictor ß ?R2 p
• ? Income .185 .031
• ? In area on K-day .249 .048
• ? Katrina trauma .173 .131
• ? Social support -.417 .066
• ? Social sup X Cognitions .369 .112
• Total R2
  .387
  
• MI
• Predictor ß ?R2 p
• ? Katrina Trauma .184 .108
• ? Negative cognitions .339 .094
• Total R2 .202

High Neg. Cog.
Moderate Neg. Cog.
Low Neg. Cog.
41

• DV GAD Scale Score
• MI
• Predictor ß ?R2 p
• ? In affected area on K-day .151 .025
• ? Katrina trauma .161 .198
• ? Social support -.485 .086
• ? Soc sup X Neg cog. .495 .220
• Total R2
  .529
  
• MI
• Predictor ß ?R2 p
• ? Education -.124 .072
• ? Katrina trauma .192 .204
• ? Feelings during Katrina .139 .053
• ? Social support -.126 .070
• ? Negative cognitions .507 .176
• Total R2 .574

High Neg. Cog.
Moderate Neg. Cog.
Low Neg. Cog.
42
Conclusions

• As predicted, pre-existing mental illness does
  appear to predispose veterans to developing new
  mental disorders after facing a natural
  disaster.
• Those with PMI did report less social support and
  did exhibit more negative cognitive appraisals of
  the hurricane and their feelings and actions in
  response to it.
• Mediation analyses suggest that the group
  differences in mental health outcomes are
  partially mediated by the differences in social
  support and negative cognitions. However, PMI
  still contributes unique variance to the
  explanation of mental health outcomes.
• Exploratory analyses of within-group determinants
  of negative mental health outcomes showed some
  differences in useful predictors between the
  groups. However, negative cognitions play some
  role in every prediction for both groups.