CILR

The Journal of Emergency Medicine, Vol. 43, No. 1, pp. 76–82, 2012 Published by Elsevier Inc.

Printed in the USA 0736-4679/$ - see front matter

doi:10.1016/j.jemermed.2011.06.124

Prior Presentat Society for Aca Meeting – ‘‘Prev lowing Hurricane Mediterranean Em 2007; Southeast Annual Meeting University Medic

RECEIVED: 7 Jun ACCEPTED: 1 Jun

Selected Topics: Disaster Medicine

POST-TRAUMATIC STRESS DISORDER IN AN EMERGENCY DEPARTMENT POPULATION ONE YEAR AFTER HURRICANE KATRINA

Lisa D. Mills, MD,* Trevor J. Mills, MD, MPH,†‡ Marlow Macht, MD,§ Rachel Levitan, MD,k Annelies De Wulf, MD,†‡ and Natasha S. Afonso, MD{

*Department of Emergency Medicine, University of California Davis, Davis, California, †Section of Emergency Medicine, Louisiana State University Health Science Center, New Orleans, Louisiana, ‡Department of Veterans Affairs, New Orleans, Louisiana, §Department of

Emergency Medicine, Denver Health Medical Center, Denver, Colorado, kDepartment of Emergency Medicine, Maricopa Medical Center, Phoenix, Arizona, and {Department of Pediatrics, Weill Medical College of Cornell University, New York, New York

Reprint Address: Trevor J. Mills, MD, MPH, Section of Emergency Medicine, Louisiana State University Health Science Center, 2021 Perdido Street, New Orleans, LA 70115-3843

, Abstract—Background: Hurricane Katrina resulted in a significant amount of injury, death, and destruction. Study Objectives: To determine the prevalence of, and risk factors for, symptoms of post-traumatic stress disorder (PTSD) in an emergency department (ED) population, 1 year after hurricane Katrina. Methods: Survey data including the Primary Care PTSD (PC-PTSD) screening instrument, de- mographic data, and questions regarding health care needs and personal loss were collected and analyzed. Results: Seven hundred forty-seven subjects completed the survey. The PC-PTSD screen was positive in 38%. In the single variate analysis, there was a correlation with a positive PC-PTSD screen and the following: staying in New Orleans during the storm (odds ratio [OR] 1.73, 95% confidence in- terval [CI] 1.28–2.34), having material losses (OR 1.64, 95% CI 1.03–2.60), experiencing the death of a loved one (OR 1.96, 95% CI 1.35–1.87), needing health care during the storm (OR 2.01, 95% CI 1.48–2.73), and not having health care needs met during the storm (OR 2.00, 95% CI 1.26– 3.18) or after returning to New Orleans (OR 2.29, 95% CI

ions: ‘‘Top Ten Most Newsworthy Abstracts’’ demic Emergency Medicine 2007 Annual alence of Posttraumatic Stress Disorder Fol- Katrina’’; also presented at the 4th Annual ergency Medicine Congress, Sorrento, Italy Society of Academic Emergency Medicine 2007; and the Eighteenth Annual Tulane al School Research Day 2007.

e 2010; FINAL SUBMISSION RECEIVED: 2 February e 2011

76

1.40–3.73). In the multivariate analysis, the death of a loved one (OR 1.87, 95% CI 1.26–2.78), being in New Orleans dur- ing the storm (OR 1.69, 95% CI 1.22–2.33), and seeking health care during the storm (OR 1.69, 95% CI 1.22–2.35) were associated with positive PC-PTSD screens. Conclu- sions: There was a high prevalence of PTSD in this ED pop- ulation surveyed 1 year after hurricane Katrina. By targeting high-risk patients, disaster relief teams may be able to reduce the impact of PTSD in similar popula- tions. Published by Elsevier Inc.

, Keywords—post-traumatic stress disorder; public health; disaster response; hurricane Katrina

INTRODUCTION

Hurricane Katrina made landfall on the Gulf Coast of southeast Louisiana on the morning of Monday, August 29, 2005. The storm resulted in the most property damage ever caused by a natural disaster, and the most deaths caused by a natural disaster since 1928 (1). Over 1300 people were killed and $100 billion in assets were dam- aged (1). An estimated 300,000 homes were completely destroyed or made uninhabitable (2). In New Orleans, 80% of the metropolitan area flooded (3). Thousands who remained in New Orleans during the storm and its

2011;

PTSD in an ED Population after Katrina 77

aftermath experienced significant stressful events, includ- ing exposure to extreme environmental conditions, hu- man suffering, death, and violent behavior.

Hurricane evacuees also endured difficult circum- stances. For those who evacuated from New Orleans, na- tional television news coverage showed flooded property, looting, and violence. These images may have affected evacuees as they witnessed the destruction of their city. Evacuees also directly dealt with lack of food and water, heat, and unsafe living conditions. For those who returned to post-Katrina New Orleans, there were continuing hard- ships. Many were displaced from their homes, lived in shelters or mobile homes, and experienced the lack of ba- sic resources, such as electricity, water, telephone service, and a reduced police force and health care system.

The diagnostic criteria for post-traumatic stress disor- der (PTSD) stipulate the exposure to an inciting event that involves actual or threatened death, or serious injury, to oneself or others. Symptoms of PTSD include persis- tently re-experiencing the traumatic event and consis- tently avoiding stimuli associated with the trauma (4).

An estimated 7.8% of Americans will experience PTSD at some point in their lives, corresponding with an estimated 3.6% of adults aged 18–54 years who will have PTSD in the course of a given year (5,6). Factors associated with the development of PTSD symptoms include psychiatric comorbidities and poor social support (5). In prior studies of survivors of disasters, fac- tors associated with the development of PTSD included fear during the traumatic event, past traumatic experi- ences, damage to the home, high levels of material loss, loss of a loved one, continuing stressors, and continual re- minders of the trauma (7–11). Female gender has been associated with increased risk of development of PTSD symptoms, however, this remains a subject of debate (5,12). Furthermore, a person does not need to be physically present at a traumatic event to develop PTSD (13,14). People have been diagnosed with PTSD after experiencing a traumatic event via the news, losing a loved one, or hearing stories of a traumatic event.

Our hypothesis is that the stressors of the storm, both during and immediately after hurricane Katrina, resulted in a significant amount of PTSD in the population of New Orleans. The purpose of this study was to determine the prevalence of, and risk factors for, symptoms of PTSD in an emergency department (ED) population, 1 year after hurricane Katrina.

MATERIALS AND METHODS

Study Design

This cross-sectional study was conducted over 6 weeks in July and August of 2006, 11–12 months after hurricane

Katrina struck the Gulf Coast. During each day of the study period, in randomly selected 6-h blocks, research personnel approached all people in the waiting room of an interim public ED to assess eligibility and request con- sent for an interview. The Louisiana State University Health Science Center Institutional Review Board ap- proved this study.

Study Setting and Population

Inclusion criteria were age $ 18 years at the time of the study, those who were residents of the greater New Orleans area at the time of the storm, and those who gave verbal consent to answer the study questions. The setting was the waiting room of the only operating public ED within the city limits of New Orleans at the time. Charity Hospital, one of the longest continually operating public hospitals in the country, was closed 5 days after Katrina’s landfall. In the year immediately after Katrina, emergency care was delivered in a number of temporary settings, including tents, the convention center, a Navy ship, and a parking lot. At the time of the study, the Loui- siana State University Interim Hospital had just opened and the ED had a calculated volume of approximately 45,000 patient visits a year.

Study Protocol and Measurements

Trained research assistants conducted interviews using a structured questionnaire that included demographics, location of the person during the storm, material losses, the experience of the death of a loved one, and health care needs during and after Katrina. Material loss in- cluded loss of an owned home, rented home, car, job, pet, or personal property. The health care needs questions were ‘‘yes/no’’ and included the questions ‘‘did you need health care during or after the storm’’ and if yes, ‘‘was it available?’’ The final items on the questionnaire were the four questions of the Primary Care PTSD Screen (PC- PTSD) (Table 1) (15). Although the questions are phrased in the past tense, patients were instructed to relate their symptoms at the time of the interview.

Participants with a positive screen were given written information about local free mental health resources, and encouraged to attend. There were no inpatient psychiatric or psychiatric consultation services available at the time of the study in the city of New Orleans.

Data Analysis

The primary dependent variable was a positive PC-PTSD screen. A positive screen was defined as ‘‘yes’’ answers to three of four items on the screen. This cutoff was selected to maximize the specificity of the screen. In the study

Table 1. The Primary Care PTSD Screen (PC-PTSD)

In your life have you ever had any experience that was so frightening, horrible, or upsetting that in the past month you:

1. Have had nightmares about it or thought about it when you did not want to? 2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? 3. Were constantly on guard, watchful, or easily startled? 4. Felt numb or detached from others, activities, or your surroundings?

PTSD = post-traumatic stress disorder.

78 L. D. Mills et al.

validating this screen, a cutoff of three gives a sensitivity of 0.78, with a specificity of 0.87, for an efficiency of 0.85 in a population of veterans with a PTSD prevalence of 24.5% (15).

The data were analyzed in Stata 9.2 (StataCorp, Col- lege Station, TX). The data were first analyzed utilizing univariate analysis, examining the relationship between a positive PC-PTSD screen and gender, age (stratified by decade), staying in New Orleans during the storm, ex- periencing material losses, experiencing the death of a loved one, needing health care either during the storm or after returning to New Orleans, and whether or not health care needs were met. For those who had material losses, the specific material losses were also analyzed. The categories of losses that were analyzed were owned home, rented house, other personal property, car, pet, and job. The responses to each of these questions were bi- nary, except for deaths, where we included ‘‘unknown’’ as a response for a missing but not confirmed dead relative. All tests were two-tailed, with significance defined as p < 0.05. The chi-squared test statistic was used except where Fisher’s exact test was more appropriate.

To evaluate for interviewer bias, we tested for correla- tion between each of the six interviewers and a positive screen. There was no correlation between interviewer and positive PTSD screens (Pearson chi-squared 6.4, p = 0.265).

After completing the single variable analysis, vari- ables were entered into a multivariable logistic regression model, to allow adjustment for confounders. Due to the expected colinearity, health care needs were included in the multivariable model, but whether those health care needs were met was not included. Model fit was assessed with the Hosmer-Lemeshow goodness-of-fit test. The dis- criminatory power of the model was investigated by gen- erating a receiver operating characteristic curve for the model and evaluating the area under the curve.

RESULTS

In the study period, 1181 people were approached, and 201 (17%) did not meet study criteria. Those who did not meet criteria were under 18 years of age or were not in New Orleans at the time of Katrina. Of the 908 el- igible people, 783 (86%) consented and 747 (95%) peo-

ple completed the interview. The primary reason for incomplete interviews was being called into the ED be- fore completion of the interview. The prevalence of pos- itive PC-PTSD screen in the population studied was 38% (95% confidence interval [CI] 34.7–41.8%).

Demographics

Four hundred ten (55%) participants were women. The mean age of participants was 42.2 years (SD 6 14.3 years). Thirty-nine percent of participants reported stay- ing in New Orleans during the storm. Among the factors analyzed, the most common was material loss, reported by 87% (n = 648) of respondents. Of the material losses reported, 459 (61% of total study participants) reported the loss of a home, 209 reported loss of a home that they owned, and 250 reported loss of a rented home. Five hundred ninety-one (79%) reported loss of personal property of value, 287 (38%) reported loss of a car, 89 (12%) reported loss of a pet, and 157 (21%) reported loss of a job site.

Eighteen percent (n = 134) of participants experienced the death of a loved one as a result of the storm. Over half of the participants reported needing health care during the storm (56%, n = 418) or after returning to New Orleans (55%, n = 409). Of those who needed health care, 23% (n = 95) reported that their needs were not met during the storm. Twenty percent (n = 81) reported that their health care needs were not met upon returning to the city (Table 2).

Single-variable Analysis

There was no significant correlation between age (by de- cade) and positive PC-PTSD screens (Pearson chi- squared 14.1, p = 0.050). The data do show a significant correlation with a positive PC-PTSD screen and staying in New Orleans during the storm (OR 1.73, 95% CI 1.28–2.34), having material losses (OR 1.64, 95% CI 1.03–2.60), experiencing the death of a loved one (OR 1.96, 95% CI 1.35–1.87), needing health care during the storm (OR 2.01, 95% CI 1.48–2.73), and not having health care needs met either during the storm (OR 2.00, 95% CI 1.26–3.18) or after returning to New Orleans (OR 2.29, 95% CI 1.40–3.73) (Table 3).

Table 2. Demographics of Study Participants (n = 747)

Number Percent

Positive PC-PTSD screen 285 38 Female gender 410 55 In New Orleans during Katrina 288 39 Experienced material loss 648 87

Home 459 61 Owned home 209 28 Rented home 250 34 Car 287 38 Other personal property of value 591 79 Job 157 21 Pet 89 12

Experienced death of a loved one 134 18 Needed health care during storm 418 56

Needed health care during storm but not available (For this percentage, n = 481)

95 23

Needed health care after storm 409 55 Needed health care after storm but not

available (For this percentage, n = 409) 81 20

PC-PTSD = primary care post-traumatic stress disorder.

PTSD in an ED Population after Katrina 79

Multi-variable Analysis

Female gender, being in New Orleans during the storm, experiencing material losses, experiencing the death of a loved one, and needing health care during the storm or after returning were entered into the logistic regression model. (Because there were only 27 participants over 65 years of age, age was not entered into the logistic regres- sion model.) For this model, the Hosmer-Lemeshow goodness-of-fit statistic was calculated at c

2(8) = 2.96, p = 0.94. The area under a receiver operating characteris- tic curve fitted to evaluate goodness of fit was 0.64, indi- cating an adequate discriminatory power for the model.

In this model, experiencing the death of a loved one carried the highest odds of a positive PC-PTSD screen (OR 1.87, 95% CI 1.26–2.78). Being in New Orleans dur- ing the storm (OR 1.69, 95% CI 1.22–2.33) and seeking health care during the storm (OR 1.69, 95% CI 1.22– 2.35) were also associated with positive PC-PTSD screens. There was no significant correlation with female gender (OR 1.21, 95% CI 0.88–1.67), material losses (OR

Table 3. Single-variable Analysis of a Positive PC-PTSD Screen and Risk Factors

OR Low High p Value

Female gender 1.21 0.90 1.64 0.1943 In New Orleans during Katrina 1.73 1.28 2.34 0.0003 Material losses 1.64 1.03 2.60 0.0352 Death of a loved one 1.96 1.35 2.87 0.0004 Needed health care during storm 2.01 1.48 2.73 0.0000 Health care not available during storm 2.00 1.26 3.18 0.0031 Needed health care after returning 1.14 0.85 1.53 0.3898 Health care not available after returning 2.29 1.40 3.73 0.0008

PC-PTSD = primary care post-traumatic stress disorder; OR = odds ratio.

1.12, 95% CI 0.81–1.56), or seeking health care after re- turning (OR 1.12, 95% CI 0.81–1.56) (Figure 1).

DISCUSSION

As hypothesized, we found a high prevalence (38.2%) of PTSD in the population of New Orleans 1 year after hur- ricane Katrina. This result is supported by other studies conducted after the hurricane. A survey of the largest em- ployer in the city 6 months after hurricane Katrina found a PTSD rate of 19.2% (16). A separate study of police and firefighters conducted by the Centers for Disease Control and Prevention in the 2–3 months after the hurricane showed a prevalence of PTSD rates of 19% and 22%, re- spectively (17). Previous studies indicate that PTSD symptoms may become chronic, with one- to two-thirds of those suffering PTSD symptoms having incomplete resolution years after the traumatic event (5,10,18,19).

Figure 1. Multivariable analysis of positive PC-PTSD (primary care post-traumatic stress disorder) screen and risk factors. NOLA = New Orleans, Louisiana; Material losses = exper- ienced material losses during Katrina; HC = health care; Needed HC during = needed health care during Katrina; Needed HC after = needed health care after Katrina.

80 L. D. Mills et al.

Before the recent oil spill, unpublished data indicate that levels of PTSD on the Gulf Coast continue to increase, with PTSD prevalence up to 16–21% (20).

A number of variables were shown to be significantly associated with the development of PTSD symptoms. Nineteen percent of those interviewed reported the loss of a loved one due to the hurricane. In both the univariate and multivariate analysis, this was the most significant risk factor for developing PTSD. In preparing for future disasters, mental health services can potentially target those who experience deaths in the family for early inter- vention and services.

Having health care needs during the storm (56%) was associated with PTSD. In addition, of those who needed health care, those whose health care needs were not met either during the hurricane (22%) or afterwards (20%) were more likely to have a positive PTSD screen. Al- though the causation is not clear, it is possible that those individuals whose needs were not met were predisposed to developing PTSD. Conversely, those with PTSD may have been more likely to seek care or feel that their needs were not met if their mental health conditions were not addressed. The association between the need for health care, those needs being unmet, and a positive PTSD screen has important implications for disaster planning. This study suggests that a robust response with attention to health care needs, both for medical care and mental health, may reduce the prevalence of PTSD and increase well-being after a natural disaster.

Women made up roughly half of the interviewed pop- ulation (55%). In this study, female gender was not asso- ciated with a significantly increased likelihood of developing PTSD symptoms. In previous disaster studies, the increased prevalence of women with PTSD has been linked to increased rates of trauma, such as rape and inti- mate partner violence (12). Although there were multiple media reports of sexual assault after the storm, a gender difference in PTSD was not seen in our study.

Eighty-seven percent of those interviewed reported material losses due to the storm. Unlike previous studies that reported an increased risk of PTSD symptoms with higher levels of material loss, no significant correlation between positive PTSD screens and personal material loss was found in this investigation (10). A possible ex- planation is that material losses were present in the vast majority of residents interviewed. Because material los- ses were so prevalent in this cohort, this factor may have less value as a predictor of a positive screen.

Because PTSD can have a detrimental effect on phys- ical health, the prevalence of PTSD in New Orleans has implications for the overall health of this community. A study examining health problems in Vietnam War combat veterans noted that those with a concurrent diagnosis of PTSD were more likely to have physical health problems,

and that those with more severe PTSD symptoms also had more physical problems (21). This evidence is particu- larly concerning in the context of the health care crisis in New Orleans. As of July 2007, only three of the seven previously operating hospitals were open, two of which were at partial capacity, dropping the total number of hos- pital beds by two-thirds (22). Furthermore, the health care workforce was drastically reduced. The Louisiana De- partment of Health and Hospitals reported in April 2006 that there was less than one primary care physician for every 3200 residents and less than one psychiatrist for every 21,000 residents (23).

The high PTSD prevalence in New Orleans impacts the safety of all members of the community. After the hurricane, violent crime in the city increased dramatically and has remained high. Violent crime is associated with PTSD. According to a study of northern Ugandans ex- posed to years of brutal conflict, those who exhibited symptoms of PTSD or depression were more likely to choose violent than non-violent means of conflict resolu- tion and have a desire for retribution than those without symptoms of PTSD (24). A separate study found that Congolese and Ugandan child soldiers with symptoms of PTSD were less open to reconciliation and had more feelings of revenge (25). In pre-Katrina New Orleans, es- timates of murder rates by population made it the deadli- est city in the United States, with rates rising since 2004 (26). Although the exact homicide rate in 2006 is hard to pin down, due to variable estimates of the remaining pop- ulation, by even the most generous population estimates, in the year after hurricane Katrina, New Orleans main- tained the highest homicide rate in the country. It is pos- sible that the high prevalence of PTSD in New Orleans contributes to the violence seen in the city.

Despite the high level of PTSD in this study, as well as mental health issues seen in several other studies, avail- ability of mental health care 1 year after Katrina remained limited in New Orleans (16,17). There were limited mental health clinics as well as inpatient beds, and patients often waited for days in the EDs for inpatient placement.

When planning for immediate and long-term disaster relief, it is clear that mental health needs must be ad- dressed. With early identification and treatment of a pop- ulation at risk for PTSD, symptoms may be reduced and the overall health of the community could be improved.

Limitations

By virtue of being in an ED waiting room, participants may have had a higher pre-test likelihood of illness and injury. Because it was a public hospital, those interviewed also may have been of a lower socioeconomic status, thus having a higher likelihood of PTSD risk factors such as

PTSD in an ED Population after Katrina 81

concurrent stressors, lower baseline health status, and previous trauma.

We did not examine concurrent psychiatric disorders. Given the high prevalence of comorbidities in individuals with PTSD, it is likely that high rates of other anxiety and mood disorders also exist in this population.

We did not screen for sexual assault. Patients who expe- rienced thistype of assault may have a higher rateof PTSD.

Another limitation is the voluntary nature of the inter- view, which could not be avoided. Those who refused an interview may have done so due to the emotional content of the interview, concurrent stresses, fatigue, somatic complaints, or other factors that may have altered PTSD screen results.

Due to the setting, as well as time and resource limita- tions for the interviews, we performed a screening test, rather than using more complete PTSD inventories or a complete psychiatric interview. Given the high specific- ity of the screen, we felt that this screen effectively bal- anced time and accuracy.

This study measured prevalence of PTSD symptoms 1 year after hurricane Katrina, not the incidence. Without previous studies of PTSD prevalence in this population, we cannot assume that the high prevalence of positive PTSD screens is solely associated with experiencing the hurricane. It is possible that the population studied in this cohort had previously higher rates of PTSD than the general population of the United States.

CONCLUSION

The response to national disasters continues to evolve, and includes the leadership of emergency physicians. In this study, there was a high prevalence of PTSD in post- Katrina New Orleans. Staying in New Orleans, experi- encing the death of a loved one, and needing health care during the storm were associated with significantly increased odds of having symptoms of PTSD. By target- ing patients in the ED for referral and treatment, disaster relief teams may be able to reduce the impact of PTSD in similar populations.

Acknowledgments—The authors would like to thank Katie Hall and Makalah Solway for their assistance in performing inter- views. Additionally, we appreciate Dr. Jan Johnson’s input on this manuscript. Finally, we would like to thank the participants of this study, who told us their stories.

REFERENCES

1. Hurricane Katrina: lessons learned - Chapter One: Katrina in per- spective; 2007. Available at: http://www.whitehouse.gov/reports/ katrina-lessons-learned/. Accessed September 9, 2008.

2. Chertoff M. Statement of Michael Chertoff, US Department of Homeland Security before the Senate Committee on Homeland Security and Governmental Affairs. Homeland Security Digital Library 2006;848:1.

3. Knabb RD, Rhome JR, Brown DP. Tropical cyclone report: Hurri- cane Katrina, August 23–30, 2005. National Hurricane Center. Available at: http://www.disastersrus.org/katrina/TCR-AL122005_ Katrina.pdf. Accessed December 12, 2005.

4. American Psychiatric Association. Diagnostic and statistical man- ual of mental disorders: DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.

5. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Post- traumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995;52:1048–60.

6. Executive summaryof mental health: a report from the SurgeonGen- eral; 2007 (Chapter 2). Available at: http://www.surgeongeneral. gov/library/mentalhealth/home.html. Accessed December 12, 2007.

7. Galea S, Ahern J, Resnick H, et al. Psychological sequelae of the September 11 terrorist attacks in New York City. N Engl J Med 2002;346:982–7.

8. North CS, Nixon SJ, Shariat S, et al. Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA 1999; 282:755–62.

9. Basoglu M, Kilic C, Salcioglu E, Livanou M. Prevalence of post- traumatic stress disorder and comorbid depression in earthquake survivors in Turkey: an epidemiological study. J Trauma Stress 2004;17:133–41.

10. Armenian HK, Morikawa M, Melkonian AK, et al. Loss as a deter- minant of PTSD in a cohort of adult survivors of the 1988 earth- quake in Armenia: implications for policy. Acta Psychiatr Scand 2000;102:58–64.

11. Goenjian AK, Steinberg AM, Najarian LM, Fairbanks LA, Tashjian M, Pynoos RS. Prospective study of posttraumatic stress, anxiety, and depressive reactions after earthquake and political vio- lence. Am J Psychiatry 2000;157:911–6.

12. Yehuda R. Post-traumatic stress disorder. N Engl J Med 2002;346: 108–14.

13. Dixon P, Rehling G, Shiwach R. Peripheral victims of the Herald of Free Enterprise disaster. Br J Med Psychol 1993;66:193–202.

14. Schuster MA, Stein BD, Jaycox L, et al. A national survey of stress reactions after the September 11, 2001, terrorist attacks. N Engl J Med 2001;345:1507–12.

15. Prins A, Ouimette P, Kimerling R, et al. The primary care PTSD screen (PC-PTSD): development and operating characteristics. Prim Care Psychiatr 2004;9:9–14.

16. DeSalvo KB, Hyre AD, Ompad DC, Menke A, Tynes LL, Muntner P. Symptoms of posttraumatic stress disorder in a New Or- leans workforce following Hurricane Katrina. J Urban Health 2007; 84:142–52.

17. Centers for Disease Control and Prevention (CDC). Health hazard evaluation of police officers and firefighters after Hurricane Katrina: New Orleans, Louisiana, October 17–28 and November 30–December 5, 2005. MMWR Morb Mortal Wkly Rep 2006;55: 456–8.

18. Norris FH, Murphy AD, Baker CK, Perilla JL. Postdisaster PTSD over four waves of a panel study of Mexico’s 1999 flood. J Trauma Stress 2004;17:283–92.

19. North CS, Kawasaki AMSW, Spitznagel EL, Hong BA. The course of PTSD, major depression, substance abuse, and somatization after a natural disaster. J Nerv Ment Dis 2004;192:823–9.

20. Mental health on the decline in the Gulf Coast - Mental Health. MSNBC.com. August 21, 2007. Available at: http://www.msnbc. msn.com/id/20381086. Accessed December 2007.

21. Beckham JC, Moore SD, Feldman ME, Hertzberg MA, Kirby AC, Fairbank JA. Health status, somatization, and severity of posttraumatic stress disorder in Vietnam combat veterans with posttraumatic stress disorder. Am J Psychiatry 1998;155: 1565–9.

22. Eaton L. New Orleans recovery is slowed by closed hospitals. The New York Times July 24, 2007.

82 L. D. Mills et al.

23. Department of Health and Hospitals, State of Louisiana. Primary care and rural health; 2007. Available at: http://www.dhh.louisiana.gov/ offices/news.asp?ID=88&Detail=857. Accessed September 9, 2008.

24. Vinck P, Pham PN, Stover E, Weinstein HM. Exposure to war crimes and implications for peace building in northern Uganda. JAMA 2007;298:543–54.

25. Bayer C, Klasen F, Adam H. Association of trauma and PTSD symptoms with openness to reconciliation and feelings of revenge among former Ugandan and Congolese child soldiers. JAMA 2007;298:555–9.

26. VanLandingham MJ. Murder rates in New Orleans, La, 2004–2006. Am J Public Health 2007;97:1614–6.

ARTICLE SUMMARY

1. Why is this topic important? Emergency physicians continue to be on the forefront

of disaster response. The disaster response team should consider the immediate and delayed mental health needs of affected populations to be part of overall health. 2. What does this study attempt to show?

This study shows the mental health impact of a major natural disaster. 3. What are the key findings?

Key findings include the fact that a significant number of individuals had symptoms of post-traumatic stress dis- order 1 year after hurricane Katrina. 4. How is patient care impacted?

Health care, including mental health, is an integral part of disaster relief and rebuilding. This response requires prolonged individual, local, state, and national resources. This study reveals the impact of a natural disaster on the mental health of a population hurt by a storm and ham- pered by a slow recovery.