PTSD and Depression 8 Years After the 2004 Tsunami in Sri Lanka.

OBJECTIVES: To evaluate prevalence and risk factors of posttraumatic stress disorder (PTSD) and depression among directly exposed (DE) and indirectly or nonexposed (INE) populations in Sri Lanka 8 y after the Indian Ocean Tsunami in 2004. METHODS: Population-based structured survey study was conducted among Sri Lankan adults living in 5 coastal districts, Hamboantha, Matara, Galle, Kalutara, and Colombo in 2012-2013. A total of 430 individuals, 325 in DE, 105 in INE, participated in the survey. DE and INE groups were compared for demographics and outcomes. Bivariate and multiple logistic regressions with backward selection were used to identify risk factors for partial PTSD and depression. RESULTS: The prevalence of PTSD, partial PTSD and depression were 2.8%, 10.5%, and 18.8% in DE group, respectively. In multivariable analyses tsunami exposure, female gender, subjective physical health before the tsunami, previous trauma, and depression were significantly associated with partial PTSD. Female gender, high frequency of religious activity, previous trauma, social support, and PTSD were significantly associated with depression. CONCLUSIONS: The psychological impacts of the tsunami did wane over time, but still present at lower rate even in 8 y. It is important to address these lingering sequelae and expand access to at risk individuals.

Leadership Principles to Decrease Psychological Casualties in COVID-19 and Other Disasters of Uncertainty.

Coronavirus disease (COVID-19) is a "disaster of uncertainty" with ambiguity about its nature and trajectory. These features amplify its psychological toxicity and increase the number of psychological casualties it inflicts. Uncertainty was fueled by lack of knowledge about the lethality of a disaster, its duration, and ambiguity in messaging from leaders and health care authorities. Human resilience can have a buffering effect on the psychological impact. Experts have advocated "flattening the curve" to slow the spread of the infection. Our strategy for crisis leadership is focused on flattening the rise in psychological casualties by increasing resilience among health care workers. This paper describes an approach employed at Johns Hopkins to promote and enhance crisis leadership. The approach is based on 4 factors: vision for the future, decisiveness, effective communication, and following a moral compass. We make specific actionable recommendations for implementing these factors that are being disseminated to frontline leaders and managers. The COVID-19 pandemic is destined to have a strong psychological impact that extends far beyond the end of quarantine. Following these guidelines has the potential to build resilience and thus reduce the number of psychological casualties and speed the return to normal - or at least the new normal in the post-COVID world.

Phases of psychological response in COVID-19: A preliminary heuristic.

OBJECTIVE: To explore the putative phases of the psychological response to disaster: preimpact, impact, heroic, honeymoon, disillusionment, and recovery, and make recommendations for corresponding interventions. CONCLUSIONS: Disasters such as the COVID-19 pandemic are often characterized by chaos and uncertainty. As a result, public health disaster planning and response represent formidable challenges. Although disasters can result from a wide array of hazards, regardless of the agent at work, they may follow a rather predictable trajectory of psychological phases. A heuristic of those phases can provide an opportunity for a more organized disaster mental health response and more efficient utilization of scarce resources.

Psychological first aid (PFA) and disasters.

A disaster is commonly thought of as an occurrence that results in property damage and physical injuries that exceed the response capabilities of local resources. History teaches that disasters also result in a surge in demand for psychological support amongst survivors and disaster responders. This surge quickly exceeds local response capacities and has the potential to exceed even the mental health resources that may be imported from neighbouring jurisdictions and disaster relief agencies. Efficient and effective acute mental health intervention is, therefore, needed. However, the effectiveness of traditional multi-session counselling during and shortly after disasters has been questioned. Instead, the utilization of efficient and effective crisis-focussed psychological interventions has been suggested as acute phase alternatives. This paper asserts psychological first aid (PFA) may be considered a specific crisis-focussed disaster mental health intervention for use during and after disasters. PFA is designed for use in assessing and mitigating acute distress, while serving as a platform for psychological triage complementing more traditional psychological and psychiatric interventions. PFA may be employed by mental health clinicians as well as 'peer responders'.

A Randomized Controlled Trial Assessing the Efficacy of Group Psychological First Aid.

A randomized controlled trial assessed the efficacy of group psychological first aid (PFA) by comparing the Johns Hopkins RAPID-PFA model with a group conversation condition in 119 participants using the state version of State Trait Anxiety Scale and the Positive and Negative Affect Schedules. Both groups showed similar baseline scores, and after watching a distressing 5-minute video, both groups showed similar significant increases in state anxiety scores and negative affect scores, as well as similar decreases in positive affect scores. However, compared with the group conversation condition, the RAPID-PFA group evidenced significantly lower state anxiety scores at postintervention and at 30-minute delay. RAPID-PFA, compared with the group conversation condition, was also more effective in lowering negative affect scores postintervention, and significantly increasing positive affect scores at 30-minute delay. These results support the two primary goals of PFA, which are mitigating acute distress and instilling hope.

Political Affiliation, Probable PTSD, and Symptoms of Depression in Iraq and Afghanistan Combat Veterans: A Pilot Study.

Ideological commitment of military personnel has been associated with mitigating trauma and protecting mental health. This pilot study assessed whether Democratic and Republican political affiliation differentially predicted probable posttraumatic stress disorder (PTSD) and symptoms of depression in 62 male Iraq and Afghanistan combat veterans. The Liberalism-Conservatism Scale, the PTSD Checklist-Military Version (PCL-M), and the Patient Health Questionnaire-9 (PHQ-9) were assessment measures. Results revealed that Democratic combat veterans had stronger liberal attitudes than Republican combat veterans (r = 0.95). Moreover, of the 50% of the entire sample higher than the cutoff score of 50 on the PCL-M, 84.8% were Democrats compared with 10.3% of Republicans. On the PHQ-9, 46.9% of Democrats compared with 3.7% of Republicans were higher than the cutoff score of 20. These initial results suggest possible mechanisms of action, including differences in shattered world view assumptions, willingness to disclose emotional concerns, and physiological reactions between Democratic and Republican combat veterans.

The Potential Efficacy of Psychological First Aid on Self-Reported Anxiety and Mood: A Pilot Study.

The authors explored the efficacy of a randomized controlled trial to assess the potential benefits of psychological first aid (PFA) compared with a social acknowledgement condition in a sample of 42 participants who spoke about a stressful life event. Demographics and standardized questionnaires, including the state version of the State Trait Anxiety Inventory Scale and the Brief Profile of Mood States, assessed anxiety and mood state. Those in the PFA group evidenced significantly lower anxiety scores at 30-minute postdisclosure than at baseline and, although not significant, showed lowered distressed mood compared with baseline at 30-minute postdisclosure. Those in the social acknowledgment condition evidenced increases in anxiety and distressed mood scores, albeit not significantly, at 30 minutes post disclosure compared with their baseline scores. These results provide preliminary empirical evidence for the efficacy of PFA, and implications for intervention and additional assessment are suggested.

Child debriefing: a review of the evidence base.

INTRODUCTION: Debriefing, a controversial crisis intervention delivered in the early aftermath of a disaster, has not been well evaluated for use with children and adolescents. This report constitutes a review of the child debriefing evidence base. METHODS: A systematic search of selected bibliographic databases (EBM Reviews, EMBASE, ERIC, Medline, Ovid, PILOTS, PubMed, and PsycINFO) was conducted in the spring of 2014 using search terms related to psychological debriefing. The search was limited to English language sources and studies of youth, aged 0 to 18 years. No time limit was placed on date of publication. The search yielded 713 references. Titles and abstracts were reviewed to select publications describing scientific studies and clinical reports. Reference sections of these publications, and of other literature known to the authors that was not generated by the search, were used to locate additional materials. Review of these materials generated 187 publications for more thorough examination; this assessment yielded a total of 91 references on debriefing in children and adolescents. Only 15 publications on debriefing in children and adolescents described empirical studies. Due to a lack of statistical analysis of effectiveness data with youth, and some articles describing the same study, only seven empirical studies described in nine papers were identified for analysis for this review. These studies were evaluated using criteria for assessment of methodological rigor in debriefing studies. RESULTS: Children and adolescents included in the seven empirical debriefing studies were survivors of motor-vehicle accidents, a maritime disaster, hostage taking, war, or peer suicides. The nine papers describing the seven studies were characterized by inconsistency in describing the interventions and populations and by a lack of information on intervention fidelity. Few of the studies used randomized design or blinded assessment. The results described in the reviewed studies were mixed in regard to debriefing's effect on posttraumatic stress, depression, anxiety, and other outcomes. Even in studies in which debriefing appeared promising, the research was compromised by potentially confounding interventions. CONCLUSION: The results highlight the small empirical evidence base for drawing conclusions about the use of debriefing with children and adolescents, and they call for further dialogue regarding challenges in evaluating debriefing and other crisis interventions in children.

Building a national model of public mental health preparedness and community resilience: validation of a dual-intervention, systems-based approach.

OBJECTIVE: Working within a series of partnerships among an academic health center, local health departments (LHDs), and faith-based organizations (FBOs), we validated companion interventions to address community mental health planning and response challenges in public health emergency preparedness. METHODS: We implemented the project within the framework of an enhanced logic model and employed a multi-cohort, pre-test/post-test design to assess the outcomes of 1-day workshops in psychological first aid (PFA) and guided preparedness planning (GPP). The workshops were delivered to urban and rural communities in eastern and midwestern regions of the United States. Intervention effectiveness was based on changes in relevant knowledge, skills, and attitudes (KSAs) and on several behavioral indexes. RESULTS: Significant improvements were observed in self-reported and objectively measured KSAs across all cohorts. Additionally, GPP teams proved capable of producing quality drafts of basic community disaster plans in 1 day, and PFA trainees confirmed upon follow-up that their training proved useful in real-world trauma contexts. We documented examples of policy and practice changes at the levels of local and state health departments. CONCLUSIONS: Given appropriate guidance, LHDs and FBOs can implement an effective and potentially scalable model for promoting disaster mental health preparedness and community resilience, with implications for positive translational impact.

An academic-government-faith partnership to build disaster mental health preparedness and community resilience.

OBJECTIVES: Faculty and affiliates of the Johns Hopkins Preparedness and Emergency Response Research Center partnered with local health departments and faith-based organizations to develop a dual-intervention model of capacity-building for public mental health preparedness and community resilience. Project objectives included (1) determining the feasibility of the tri-partite collaborative concept; (2) designing, delivering, and evaluating psychological first aid (PFA) training and guided preparedness planning (GPP); and (3) documenting preliminary evidence of the sustainability and impact of the model. METHODS: We evaluated intervention effectiveness by analyzing pre- and post-training changes in participant responses on knowledge-acquisition tests administered to three urban and four rural community cohorts. Changes in percent of correct items and mean total correct items were evaluated. Criteria for model sustainability and impact were, respectively, observations of nonacademic partners engaging in efforts to advance post-project preparedness alliances, and project-attributable changes in preparedness-related practices of local or state governments. RESULTS: The majority (11 of 14) test items addressing technical or practical PFA content showed significant improvement; we observed comparable testing results for GPP training. Government and faith partners developed ideas and tools for sustaining preparedness activities, and numerous project-driven changes in local and state government policies were documented. CONCLUSIONS: Results suggest that the model could be an effective approach to promoting public health preparedness and community resilience.

The development of a model of psychological first aid for non-mental health trained public health personnel: the Johns Hopkins RAPID-PFA.

INTRODUCTION: The Johns Hopkins Center for Public Health Preparedness, which houses the Centers for Disease Control and Prevention-funded Preparedness and Emergency Response Learning Center, has been addressing the challenge of disaster-caused behavioral health surge by conducting training programs in psychological first aid (PFA) for public health professionals. This report describes our approach, named RAPID-PFA, and summarizes training evaluation data to determine if relevant knowledge, skills, and attitudes are imparted to trainees to support effective PFA delivery. BACKGROUND/RATIONALE: In the wake of disasters, there is an increase in psychological distress and dysfunction among survivors and first responders. To meet the challenges posed by this surge, a professional workforce trained in PFA is imperative. METHODS/ACTIVITY: More than 1500 participants received a 1-day RAPID-PFA training. Pre-/postassessments were conducted to measure (a) required knowledge to apply PFA; (b) perceived self-efficacy, that is, belief in one's own ability, to apply PFA techniques; and (c) confidence in one's own resilience in a crisis context. Statistical techniques were used to validate the extent to which the survey successfully measured individual PFA constructs, that is, unidimensionality, and to quantify the reliability of the assessment tool. RESULTS/OUTCOME: Statistically significant pre-/postimprovements were observed in (a) knowledge items supportive of PFA delivery, (b) perceived self-efficacy to apply PFA interventions, and (c) confidence about being a resilient PFA provider. Cronbach alpha coefficients ranging from 0.87 to 0.90 suggested that the self-reported measures possessed sufficient internal consistency. DISCUSSION: Findings were consistent with our pilot work, and with our complementary research initiatives validating a variant of RAPID-PFA with faith communities. LESSONS LEARNED/NEXT STEPS: The RAPID-PFA model promises to be a broadly applicable approach to extending community behavioral health surge capacity. Relevant next steps include evaluating the effectiveness of trained providers in real crisis situations, and determining if PFA training may have potential beyond the disaster context.

Psychological first aid: a consensus-derived, empirically supported, competency-based training model.

Surges in demand for professional mental health services occasioned by disasters represent a major public health challenge. To build response capacity, numerous psychological first aid (PFA) training models for professional and lay audiences have been developed that, although often concurring on broad intervention aims, have not systematically addressed pedagogical elements necessary for optimal learning or teaching. We describe a competency-based model of PFA training developed under the auspices of the Centers for Disease Control and Prevention and the Association of Schools of Public Health. We explain the approach used for developing and refining the competency set and summarize the observable knowledge, skills, and attitudes underlying the 6 core competency domains. We discuss the strategies for model dissemination, validation, and adoption in professional and lay communities.

Resilient leadership and the organizational culture of resilience: construct validation.

Political, economic, and social unrest and uncertainty seem replete throughout the world. Within the United States, political vitriol and economic volatility have led to severe economic restrictions. Both government and private sector organizations are being asked to do more with less. The specter of dramatic changes in healthcare creates a condition of uncertainty affecting budget allocations and hiring practices. If ever there was a time when a "resilient culture" was needed, it is now. In this paper we shall discuss the application of "tipping point" theory (Gladwell, 2000) operationalized through a special form of leadership: "resilient leadership" (Everly, Strouse, Everly, 2010). Resilient leadership is consistent with Gladwells "Law of the Few" and strives to create an organizational culture of resilience by implementing an initial change within no more than 20% of an organization's workforce. It is expected that such a minority, if chosen correctly, will "tip" the rest of the organization toward enhanced resilience, ideally creating a self-sustaining culture of resilience. This paper reports on the empirical foundations and construct validation of "resilient leadership".

A pilot investigation in constructing crisis communications: what leads to best practice?

Crisis communications can play an important role in mitigating, or exacerbating, the psychological and behavioral reactions to critical incidents and disasters. Effective crisis communications can serve to mitigate anxiogenesis and direct rapid and focused rescue, recovery, and rehabilitative operations. Ambiguous and/or deceptive communications can serve to worsen mental health reactions and delay operational response and recovery (Everly, Strouse, & Everly, 2010). It seems, therefore, that inquiry into the content of acute crisis communications would be warranted Said more simply, given limited time, cryptic messaging in social media, and the "sound bite" mentality that seems to govern news dissemination, it is important to identify the most important content to convey in the wake of critical incidents and disasters. This paper reports on a pilot investigation into "best practices" for the construction of acute crisis communications.

Seven characteristics of highly resilient people: insights from Navy SEALs to the "greatest generation".

Having reviewed investigative methods such as structural equation modeling, seminal manuals of war (von Clausewitz, 1976, rev. 1984; Clavell, 1983), as well as individual interviews and focus groups with highly resilient people such as Navy SEALs, law enforcement professionals, and the "children of the Great Depression" now commonly referred to as the "greatest generation," we sought to discover the common themes, or characteristics, of highly resilient people. In this paper, we present our initial impressions that there exist seven important characteristics that seem to be associated with enhanced human resilience.

The Johns Hopkins model of psychological first aid (RAPID-PFA): curriculum development and content validation.

There appears to be virtual universal endorsement of the need for and value of acute "psychological first aid" (PFA) in the wake of trauma and disasters. In this paper, we describe the development of the curriculum for The Johns Hopkins RAPID-PFA model of psychological first aid. We employed an adaptation of the basic framework for the development of a clinical science as recommended by Millon which entailed: historical review, theoretical development, and content validation. The process of content validation of the RAPID-PFA curriculum entailed the assessment of attitudes (confidence in the application of PFA interventions, preparedness in the application of PFA); knowledge related to the application of immediate mental health interventions; and behavior (the ability to recognize clinical markers in the field as assessed via a videotape recognition exercise). Results of the content validation phase suggest the six-hour RAPID-PFA curriculum, initially based upon structural modeling analysis, can improve confidence in the application of PFA interventions, preparedness in the application of PFA, knowledge related to the application of immediate mental health interventions, and the ability to recognize clinical markers in the field as assessed via a videotape recognition exercise.

Community capacity-building in disaster mental health resilience: a pilot study of an academic/faith partnership model.

We describe an academic/faith partnership approach for enhancing the capacity of communities to resist or rebound from the impact of terrorism and other mass casualty events. Representatives of several academic health centers (AHCs) collaborated with leaders of urban Christian-, Jewish-, and Muslim faith-based organizations (FBOs) to design, deliver, and preliminarily evaluate a train-the-trainer approach to enhancing individual competencies in the provision of psychological first aid and in disaster planning for their respective communities. Evidence of partner commitment to, and full participation in, project implementation responsibilities confirmed the feasibility of the overall AHC/FBO collaborative model, and individual post-training, self-report data on perceived effectiveness of the program indicated that the majority of community trainees evaluated the interventions as having significantly increased their: (a) knowledge of disaster mental health concepts; (b) skills (self-efficacy) as providers of psychological first aid and bereavement support services, and (c) (with somewhat less confidence because of module brevity) capabilities of leading disaster preparedness planning efforts within their communities. Notwithstanding the limitations of such early-phase research in ensuring internal and external validity of the interventions, the findings, particularly when combined with those of earlier and subsequent work, support the rationale for continuing to refine this participatory approach to fostering community disaster mental health resilience, and to promoting the translational impact of the model. An especially important (recent) example of the latter is the formal recognition by local and state health departments of program-trained lay volunteers as a vital resource in the continuum of government assets for public health emergency preparedness planning and response.