Psychiatric Aspects of Pandemic Influenza (Medical model)

[Thornton]

Article -
David J. Rissmiller, DO and Robert A. Steer Psychiatric Aspects of the Impending Avian Flu Pandemic . Psychiatric Times December 01, 2007 Vol. 24 No. 14
This is article is the only one of its kind that I have seen. I commend the authors and the editors for its publication. I provide the link and then excerpts.
Link to article

http://www.psychiatrictimes.com/showArticle.jhtml;jsessionid=LVQ34QKZ5VG4UQSNDLOSKHSCJUNN2JVN?articleID=204701785&pgno=2

Outline ?
Psychiatrists' role in a pandemic - Psychological Impact of SARS -CDC computer model fluSurge 2.0

Using these rates as end points, we calculate that there would be 349,192 to 502,829 admissions of patients with significant mental illness during a severe influenza pandemic

If, during a severe pandemic, 5% of admitted patients were referred, 69,837 additional psychiatric consultations would be generated during the first 12 weeks of the pandemic.

Public response to a virulent pandemic will greatly influence the magnitude of psychological comorbidity. A unified perception of shared disaster will reduce psychiatric casualties. Alternatively, a perceived bias in pandemic resource allocation, such as hospital respirators and beds (the supply of which is predicted to run out in less than 1 week)20 will fuel a fractious response that will amplify psychiatric suffering.

Do psychological factors play a role in influenza susceptibility?

Vedhara and colleagues31 established that intervention with cognitive-behavioral therapy alleviates a stress-induced diminished immune response to vaccination.

Antiviral medications

Psychiatrists will also need to be familiar with the neuropsychiatric effects of antiviral treatments

?psychiatrists should be aware that recently the Japanese Ministry for Health, Labour, and Welfare issued a warning to doctors not to prescribe oseltamivir phosphate for adolescents aged 10 to 19 years because of 54 deaths of people taking the drug (16 of these in children or adolescents), many of which occurred by suicide. Because the preponderance of cases arose in 1 country the link remains uncertain.35

Long-term psychiatric effects

The final psychiatric sequelae of an avian flu pandemic may not occur for decades. Multiple studies have demonstrated a link between schizophrenia and mothers infected with influenza in their first or second trimester.

[sharon sanders]

Re: Psychiatric Aspects of Pandemic Influenza (Medical model)

Does this paper discuss Post-Traumatic Stress Disorder?

[Thornton]

Re: Psychiatric Aspects of Pandemic Influenza (Medical model)

Does this paper discuss Post-Traumatic Stress Disorder?

Briefly, citing data from the SARS experience -

Hawryluck and colleagues7 examined the psychological effects on 129 patients quarantined during the SARS epidemic and found that 28.9% met criteria for posttraumatic stress disorder (PTSD) and 31.2% for clinical depression. Styra8 found that of 124 hospitalized SARS patients, 35% had clinical depression and 47% had symptoms of PTSD 3 months after discharge. Among those afflicted, there was a high rate of failure to return to work and carry out daily responsibilities at home.8

Significant psychological distress was also observed among physicians who provided care to patients with SARS (45.7%) compared with those who did not (17.5%).6 The reasons included the necessity of wearing protective R-95 inhalators for protracted periods, the exposure to the morbidity and mortality of coworkers, and the fear of infecting family members. The physicians found that evaluating patients and establishing any semblance of therapeutic alliance was challenging. "You are toiling under the most stressful clinical time in your professional career. You have a headache, the mask hurts, you're sweating, and it's impossible to establish any of the usual nonverbal clues with patients."9

[sharon sanders]

Re: Psychiatric Aspects of Pandemic Influenza (Medical model)

I find these numbers very disturbing. This greatly increases the collateral damage estimates.

Is there is any way to mitigate this? I know this is a complicated issue but are there any therapies or methods to diminish the mid and long term PSTD affects in an infectious disease scenario?

[Thornton]

Re: Psychiatric Aspects of Pandemic Influenza (Medical model)

Is there is any way to mitigate this?

Yes.
Resiliency and effective risk communication.
Resiliency is the total sum of factors that enable individuals and groups are better able to withstand trauma. The easy analogy is to think how training prepares athletes for events.
Effective risk communication is the single best tool for surge management by several orders of magnitude. As we avoid scenarios that see hundreds of people miling in hospital parking lots we will see less 'secondary trauma" and more effective use of scarce resources.
A good source for additional information is to study the work of Dr. Rachel Yehuda. http://www.nyas.org/ebrief/miniEB.asp?ebriefID=442
The harder task is to implement what we learn.
Joe Thornton, M.D.

[Laidback Al]

Re: Psychiatric Aspects of Pandemic Influenza (Medical model)

Alternatively, a perceived bias in pandemic resource allocation, such as hospital respirators and beds (the supply of which is predicted to run out in less than 1 week)20 will fuel a fractious response that will amplify psychiatric suffering.

In a severe pandemic I think this will be the major psychological issue, not just for the distribution and availability of medical services, but primarily for access to all basic supplies and services.

People in first world countries have developed a sense of entitlement that will quickly show itself when the time comes to allocate scare resources. I don't think it has dawned on the general public that once a severe pandemic starts there will not be enough critical resources to share among everyone, whether we are talking about vaccinations, access to medical services, or even access to the basic necessities of life.

[sharon sanders]

Re: Psychiatric Aspects of Pandemic Influenza (Medical model)

In a severe pandemic I think this will be the major psychological issue, not just for the distribution and availability of medical services, but primarily for access to all basic supplies and services.

People in first world countries have developed a sense of entitlement that will quickly show itself when the time comes to allocate scare resources. I don't think it has dawned on the general public that once a severe pandemic starts there will not be enough critical resources to share among everyone, whether we are talking about vaccinations, access to medical services, or even access to the basic necessities of life.

I agree Al.

I think in the industrialized countries there will be social unrest due to the allocation (or lack thereof) of scarce resources.

The entitlement issue is a big one. We are spoiled compared to the rest of the world.

Plain and simple.

[GaudiaRay]

Re: Psychiatric Aspects of Pandemic Influenza (Medical model)

Resiliency and effective risk communication.

Resiliency ...[snip] The easy analogy is to think how training prepares athletes for events.

Effective risk communication is the single best tool for surge management by several orders of magnitude. [snip]

The harder task is to implement what we learn.

Joe Thornton, M.D.

Dr Thornton, your contribution is very much appreciated.

The power words are RESILIENCY and EFFECTIVE RISK COMMUNICATION.

What is your assessment regarding the current quality of effective risk communication to the public in the first world, such as the USA, over the past year or two?

My own assessment is obvious. I've met with enough of those responsible to have formed a strong opinion which gets reinforced by the present utterances.

I ask for a more dispassionate response, yours.

[Thornton]

Re: Psychiatric Aspects of Pandemic Influenza (Medical model)

We have not done sufficient community exercises in the USA to know how effective our risk communication will be when the first cases of North American human H5N1 occur. We will have to rapidly learn from early missteps.
JT

[GaudiaRay]

Re: Psychiatric Aspects of Pandemic Influenza (Medical model)

Currently in the USA, among many bloggers in the real estate and financial-related areas of interest, there is an elevated antipathy towards the pronouncements by US government officials in the top senior positions.

Quoting from ml-implode.com, as one of a continuing stream, from today's summary observation of a news article about the president, '"Bush Says Markets 'Strong and Solid' - [2008-01-04] - ' "This economy is on a solid foundation," Bush said.'

As a consequence, the many tens of thousands of people who reference this news-concentrating source, receive a bias. They know that official utterances, such as "the mortgage failures will be limited to sub-prime" was wrong, and the readership is not comprised of weak-minded individuals. They independently agree with the site owner.

For government to expand resiliency, it must act in a way that forms in the public's mind "trust". Even if some information then to be delivered is inaccurate, so long as government communicates the facts accurately, including the vagaries, and especially the vagaries of the then-moment, the government has a reasonable probability of retaining its ability to "lead", to "guide", to support.

I offer this as a warning to you well in advance of the pandemic. If the government is perceived as cheating, as lying, as mis-stating simple-to-obtain, readily accessible to it information, the trust, once lost, will be exceptionally challenging to reclaim.

(If we look at Egypt now, with its dozens of people hospitalized, and unrevealed details concerning the genetic sequences, the strain, its sole reliance on only one antiviral, and its much-ado actions at the senior levels and lack of public cooperation, we witness fear and ignorance on the part of the public, mistrust of government officials, and good intentions and actions on the part of the government. There is cognitive dissonance.)

During this upcoming pandemic, you, your team, your allies, must anticipate serious and probably fatal cognitive dissonance.

(Even in the USA today, many willing buyers, who received documents from "officials", who are being foreclosed upon, have claimed a compensatory empowerment by claiming they were duped; irrespective of whether or not true, they failed to prepare and to understand, and when faced with the consequences, they are gunning for others and are in denial as to their own culpabilities. I expect nothing less and I urge you and those who are planning with you to include this as your baserock assumption as well. There will be cognitive dissonance. And the consequences in many areas will be catastrophic.)

If you are a person who has accepted the mantle of responsibility in this area, I raise this now as a specter of the Ghost of Christmas Future; either you see it and do so openly, for all its negativity it entails, or you and I, and the many reading this in the USA, at least, will be charged additionally and abundantly at the time of Level 6, and at a severity level the government yet has refused to recognize as the reality of the future (and I say this phrase because the H2H chains, irrespective of where in the world, have shown in the past, and continue in the present to show CFR's that are consistent and repeated.)

This is not our grandparents "Spanish Flu".

Your replies will be welcomed and are sought.

[GaudiaRay]

Re: Psychiatric Aspects of Pandemic Influenza (Medical model)

Please indulge me to permit me to sink one more nail of palpable understanding to a topic that resonates very similarly I believe (without real-time studies) as will pandemia.

Posted at www.jsmineset.com is the opinion of one of 3 contributors to that website which focuses on the price direction of major economic aspects of the world economy. This position, I'm about to quote, is not limited in scope among those who read the blogs.

The point to what I'm about to quote is that if those responsible for the preparation of psychological management have not anticipatorily gamed the management of the pandemic crisis, mass hysteria, mass delusion (apologies for use of technical terms undefined and arguably unsupportable) will quickly override every effort by the government. Your efforts will be not only distrusted but they will be rebuked by people who are frightened and who want whatever they define as solid, trustworthy answers, be they religious or self-help or whatever other than instruction from those responsible for social order.

In other words, if you're not prepared at a level much higher than I see here, this portends repeated failure and the worst that humans can reflect to their political environments.

The quote: "SUMMARY

In summary, we still think that prices will rise, and that people will take notice. We don't know how long the governments can keep restructuring the statistics to show a rosy picture but we can be sure that the job will get harder to do. Soon they will be unable to avoid stating the truth that we all know...inflation is (and has been) a lot higher than admitted. Even if they refuse to admit the obvious, we need only look at our own costs and the price of goods that we purchase to know the truth. Investors can only be fooled so long...they now understand the facts. We expect investors will show a preference for the themes that benefit from global growth and inflation, and that is how we are invested. "

I'll take responsibility here and be a hecubus and say that I yet see, after now nearly 5 years of attentiveness to this narrow topic, minimal chance that the government will be effective in delivering its message, even under martial law. And I don't like what I conclude one bit.

[Thornton]

Re: Psychiatric Aspects of Pandemic Influenza (Medical model)

from post #11 above

if those responsible for the preparation of psychological management have not anticipatorily gamed the management of the pandemic crisis, mass hysteria, mass delusion (apologies for use of technical terms undefined and arguably unsupportable) will quickly override every effort by the government. Your efforts will be not only distrusted but they will be rebuked by people who are frightened and who want whatever they define as solid, trustworthy answers, be they religious or self-help or whatever other than instruction from those responsible for social order.

Let me speak on "those responsible for the preparation of psychological management." As someone with some expertise in this field, the people who would fit that title are separated from the operational capacity to fulfill the responsibility. The volumes I could write on this topic would not add to the truth in the aphorisms that have become clich?. - e.g. if it doesn't work on a good day, it doesn't get better on a bad day. The experts in public mental health and the persons "in charge" at SAMSHA (USA) have provided the technical tools, training and methods for problem solving for those in power everyday and those who will have extraordinary authority during a pandemic.

As a clinician, finding blame does not cure patients, but finding a root-cause can aid in prevention for a population. Mental illness is caused by a combination of genetics plus trauma and the response to trauma. Medical interventions are one narrow aspect of the response to trauma. Public mental health as a scientific field has the evidence-base to anticipate for any given person's strengths and vulnerabilities, a guide for preparation and response to a range of traumas or traumatic conditions in order to maintain or enhance mental health. However, once we go beyond mental illness to mental health, this concept overlaps with ?life, liberty and the pursuit of happiness,? and is rightfully subject to society as a whole.

The above two paragraphs I can write in the voice of expert opinion. The rest to follow I can only speak with informed opinion. This process illustrates the catch-22 and complex emotions we experience. With my expert voice in my job and in civil discourse, I have enhanced authority, power and responsibility. (Big fish, little pond) With my informed voice I have responsibility for what I say and don?t say, but no power. (Little fish, big ocean). Additionally, what I say with my informed voice can greatly diminish the integrity of my expert voice (rarely enhance).

So looking at our situation from an informed web community, what does this clinician do? 1) prepare at home, 2) prepare at work, 3) prepare community.

(permit a brief aside ? preparation is a behavior, lets assume that we are talking about some behaviors that not everyone is doing but some of us think would be useful for them to do, then we are talking about changing behaviors. Changing behaviors is where I have both expert and informed opinion. I will just headline the basic concepts with the code words ?Prochaska and DiClemente?s Stages of Change Model? and ?Motivational Interviewing - Motivational Enhancement Therapy?)


Prepare at home ? I know all the persons, I know history values, resources, goals. I know our community as is now and how it responds. I know our dependence on the social infrastructure. At home we stockpile spiritual strength. We prepare, we strengthen our relationship with Jesus Christ our Lord and our relationship with our Catholic parish. Our values are how we live and love provide the meaning to when and how we die.
Those values include attention for those who are left out of the normal social power structures.

Prepare at work ? I am the person at my small facility who is ?responsible for the preparation of psychological management,? at least for the social community the institution represents. At my work we have daily dangers and struggle to meet with limited resources that we balance as we also stockpile to shelter in place. Here we have experience with crisis and we have a tried and true social structure. We have some material resources and I have confidence in our human resources for the facility.

Prepare community ? I suffer with anxiety and have to give it up to a higher power.
I quote Albert Schweitzer when asked about a nuclear holocaust in the late 1950s
?My knowledge is pessimistic, my faith is optimistic.?
His faith proved true.
I have done some small things locally, set up a volunteer organization to respond in health care. I certainly could spend more time and effort at a cost to home and work. But again as I examine the cost / benefits of how I allocate the resource of my time and effort, I conclude that the most important preparation is of the heart. The first and fundamental step towards true change, to prepare, is change of the heart.

So the bottom line for pandemic preparedness, global mental health, and happiness in the human experience, from my personal opinion I quote St. Thomas Aquinas - Ama Deum et fac quod vis
(Love God and do what you will).
Joe

[Snowy Owl]

Re: Psychiatric Aspects of Pandemic Influenza (Medical model)

Thank you Joe for those wise and humble words, it echoes plain Truth and granths a sense of belonging, as if reading the same page granths that.

Thanks

Snowy

[GaudiaRay]

Re: Psychiatric Aspects of Pandemic Influenza (Medical model)

Faith based viewpoints are just that, faith based viewpoints.

They are in the minority. Of course, selfless assumption of risk is most welcomed in a stress environment.

However, you've missed my point. If the gamers do not game this agressively amongst themselves, and I see nothing like that occurring, including the most recent posting by the MD who just attended the meeting of cops in DC, the disconnects will be real. The consequences can be well within what we see in Pakistan, Kenya, etc, and they're plenty faith based, because civilization is a thin veneer.

This type of talk, as if one is bouncing from cloud to cloud, will do nothing to stabilize an "insane" crowd.

If you're talking here about treating the onzies, that's necessary, but there will be no treatment with a pandemic equal to that CFR now extent plenty of places in the world.

What I don't abide is allocation of resources on shallow thinking, instead of rigorously working the logic up every branch in pursuit of clear anticipatory understandings. That's what's happening now. I can see that because I can look backwards at the datapoints and see that little has been done to seriously prepare for this biological tsunami.

I'll return to this topic; it's the core topic to the concept of preparation.

As to airy stuff about goodwill, I'd love for you or Snowy to stand in the crowd in Kenya and both stay calm and persuade it to do other than it is then either about to do or is doing.

What I think is that without the intense, responsible proactive gaming necessary, what the crowds will be facing is Kent State on steroids (hat tip to Bink), with the police state trying desperately to stop the rampages.

They can be headed off. If they aren't, all those psychological professionals, if they survive, will have plenty of new work due to the crowd participation as member or target, and its witnessing.

I hope you don't get a single new patient as a result of this pandemic; and that can happen if the planners game the strategy. Iterating, I've seen nothing in the public leadership that comes close to anticipatory resolution of decisions under stress. In fact, when the DHHS held its pretend pandemic game, the weather turned bad, and everyone went home. That says it all.

[Snowy Owl]

Re: Psychiatric Aspects of Pandemic Influenza (Medical model)

Faith based viewpoints are just that, faith based viewpoints.

_snip

This type of talk, as if one is bouncing from cloud to cloud, will do nothing to stabilize an "insane" crowd.

snip

I can see that because I can look backwards at the datapoints and see that little has been done to seriously prepare for this biological tsunami.

As to airy stuff about goodwill, I'd love for you or Snowy to stand in the crowd in Kenya and both stay calm and persuade it to do other than it is then either about to do or is doing.

Hi GR,

You say As to airy stuff about goodwill, I'd love for you or Snowy to stand in the crowd in Kenya and both stay calm and persuade it to do other than it is then either about to do or is doing.

..well, my friend, been there and done that, 10 000 people at least behind me, full of rage, of resentment, of despair and pain, but somehow, it took few of us still convinced in some universal principles with a Wind of Grace manage to stop the crowd to do the unfixable.

Of course, nothing is guarantee, but I can tell you and with this 20 years later 10 000 more people that the move initiated by few avoid much much more deaths, violence and suffering.

Life is not a mathematical equation, wealthiness is not Grace out of the Blue.

Snowy