Depression in the aftermath of disaster - transcript

Hello everyone, my name’s Leanne Humphreys and today we’re speaking with Nicole Sadler, Head of Policy and Practice here at Phoenix Australia. Nicole’s a clinical psychologist who specializes in working with high-risk organisations and has had a 23-year career as a full-time psychology officer in the army. As part of that role Nicole’s provided support for disasters both nationally and internationally.

Today’s conversation relates to the topic of depression in the aftermath of disaster.

Hello Nicole how are you?

Nicole: Hi Leanne I’m very well thank you. I hope you’re well too?

Leanne: I am thank you very much.  Nicole how common is it to see depression post a disaster?

Nicole: Leanne, as we know being involved or exposed to a disaster can impact every facet of someone’s life it has an impact on their psychological well-being their physical well-being and also those social impacts and the whole community can be impacted. So we can see where people are impacted in terms of having a low a lowered mood so a depressed mood and for some people they may even go on and develop a clinical depression.

And as we know it really doesn’t matter where they’re sitting on that spectrum it’s really important to be intervening because as we know people who are experiencing something which is sub-syndromal such as a lower mood this can increase their risk for going on and developing more clinical mental disorders if they don’t recover or you know if the right sort of support isn’t provided.

Leanne: Okay so there’s some a number of really important things that you touched on there.  One was around the multiple contributions to the development of low mood and depression and you talked about not just that idea of biological depression but in the post-disaster space there being a range of other factors so can you tease those out a little bit more for us?

Nicole: So you know the reason that a depression, that depression can be an issue for people post a disaster is because the nature of disasters themselves, there can be so many losses which are involved for people, for their families, and also for whole communities. It can be all the way from deaths or serious injuries for loved ones for, for colleagues for acquaintances or even just people that they know in the community or work colleagues it can also be the loss of animals it may be the loss of uh of livestock  it can be the loss of the family home it can be loss of  livelihood or the loss of a community and all of those things that are important to people and where they gather together and they socialize so loss of the pub,  places where people may worship, the schools, the shops, etc all of those things are you know, really impact all facets of someone’s life and it’s, that that can also mean that there’s a loss of a sense of safety you know. Where is your safe haven? Where do you come together and feel at peace and there is a sense of safety and security if you’ve lost one or perhaps multiple of those things in terms of where you find that security in your life. So yes this really is what can impact individuals and communities post a disaster and lower that mood.

Leanne: And what you’re referring to there is also something that takes time that it sounds like after a disaster mood can be lowered because rebuilding those things and coming to terms with those things is going to take quite some time in some cases isn’t it.

Nicole: Correct, and we talk about there being sometimes a vicious cycle of depression because these things have happened to someone and they lower your mood and they start to impact things like feeling bothered to get out and do different activities to reduces your motivation to engage in things that perhaps you once had felt pleasurable or that you derive some sort of sense of joy out of people start to expect that things won’t be enjoyable sometimes you’ll get this psychomotor retardation in terms of people finding it really hard to get going so engaging in any type of activity becomes really challenging people’s thinking can change you know that the negative thinking that can come in it disturbs concentration, the ability to derive pleasure from things that we used to get pleasure out of, feeling very negative or critical in your, in your thinking, ruminating about things that perhaps, that have gone wrong, thinking about the ‘what ifs’ ‘if only’ and you know because of these things it’s hard to engage in pleasurable activities or social connections and we know how vitally important social connections are in terms of rebuilding and supporting recovery and of course the longer people push other people away or socially withdraw the more diminished their social networks become so you know it’s not just that they’re withdrawing from people the social networks which are available to them start to diminish as well.

Leanne: Okay and that really leads really nicely into the idea of as, as practitioners what are the best things that we can be doing to support people who have lower mood or depression?

Nicole: So first of all do a thorough assessment which is always what we would say to do. Step number one. Exactly right but for anything that we’re seeing do a thorough assessment make sure that you’re working out what does this individual require, what’s going on for them? Don’t just think about the the mental health symptoms but also what are their other needs, what other assistance might they require, what sort of referrals, what sort of support may they require, what other services should you be thinking about linking into or ensuring that they are linking into. Knowing about services and being able to link in with them and actively engage with them of course are quite different things so you might be needing to support those things and as part of doing an assessment if you’re doing a screen for example watch out for someone if you’re looking at your DAS 21 for example look at the depression subscale are they scoring five or above on that if so then have a good look at what’s going on with this individual and in terms of their mood and whether or not it’s lowered. If you’re concerned about the fact that they might have clinical depression be making sure that you’re making a referral to a GP or to a mental health specialist you know the sorts of things that we’re looking out for of course are you know it’s the crying, it’s the negative thinking, it’s the person whose appetite or sleep may be impacted that their ability to engage in physical activities or in pleasurable activities is being impacted to be thinking about people have become very negative in their thinking in particular to be looking out for signs of of helplessness or hopelessness and of course you know they’re danger signs for us so as part of your assessment always be thinking about the requirement about whether or not you should be doing a risk assessment you know are they at risk of harm to self or to others as well  yeah and have a look for that whole idea as to whether or not there is a bit of a vicious cycle going on here. Are they reporting lower lowered mood or depressed mood because of a drop in physical and social activities? Is it something that perhaps you can ben looking at how do you reactivate their behaviours so there is more activities that they’re doing have a think about what stage they’re up to. Is there some lower level interventions that you can be doing whilst waiting for another referral? Or perhaps getting them ready to engage in more demanding psychological treatments if in fact you think that they may be indicated.

Leanne: Yeah, okay so you’re talking about really fundamental clinical processes assessment you’re looking for diagnosis risk assessment in particular you’re looking for interventions and you were talking there about the idea that as a health practitioner you might not be the only person involved in the care for that person so referral as necessary engaging with other services and, but also the idea of the behaviour talking about behavioural activation, that seems like a really nice place to think about starting with somebody even at that kind of lowered mood level that might not even be fully diagnosed diagnosable disorder so behavioural activation looks like something that a lot of practitioners could assist with.

Nicole: Yeah absolutely it’s one of those nice interventions that anyone could be doing and you can be doing it as a complementary intervention to other more formal interventions that may be occurring and as I said maybe while you’re waiting for a referral to some other interventions. So basically in terms of behavioural activation it’s a little bit of education it’s about the stuff that I just spoke about you know – why disasters can lead to lowering of the mood what that means for an individual also one of the things probably to talk about is that  sometimes depression or lower mood can come out in different ways for individuals. Anger is something that we often will see following a disaster and that might be masking some of the lowered moods so sometimes you need to be really careful in terms of the types of questioning you’re doing or the type of education that you’re doing with an individual so that they can see what’s driving that anger and what are the deeper feelings which are sitting in under that anger as well. So in terms of the, you know so psycho-education talking about the vicious cycle of depression and why it’s important to be addressing this early and then thinking about well what are the things that that individual can be doing to start to, to engage more in activities this is where we think about behavioural activation.

So, how do they increase the pleasurable events or activities that are going on and there’s some great resources that we have available here in terms of you know a pleasant activity schedule that people can fill out and really what you’re trying to do is working with this individual to come up with a bit of a list. Well what are the things that you could be, you could be engaging with which helped you improve or increase your mood? Being realistic with the person setting achievable goals um so starting off small trying to get a little bit of a balance between those sorts of activities which are likely to help them to regain a sense of mastery or control over what’s happening in their life and also increasing the number of activities that you know are just pleasurable to engage with so you can do  some really practical problem solving activities you know often there’s lots to be dealt with post a disaster so helping them to schedule those things in but also to be scheduling in some things which is just there to you know to give them some sort of social interaction or pleasurable activity.

I would also be encouraging practitioners at this stage to be doing some really good solid guided problem solving the advice that and solutions that you come up with need to be practical, they need to be realistic and they need to be cognisant of the circumstances of this individual.  Things that they may have came up come up with previously in terms of coming up with your pleasurable list of activities pre-disaster is likely to be really different post-disaster you know this person has lost their house and they’re living in their in their mother-in-law’s you know, you know spare bedroom the type of activities that you might have been able to do in terms of you know going having a bath or spending some relax relaxing time in front of the tv may not be available to them so it’s about trying to come up with some alternative things perhaps they’ve never tried before or that they’ve never had to use before as part of their schedule of events as well and importantly you know once you’ve come up with those lists helping them to think about what are the barriers that might come in, in the way of them and putting those into place and again problem solving helping them to monitor checking back in with them and helping them to adjust and encouraging them to to you know try different things this whole idea that they’re likely to come up with the best list the first time around is probably unrealistic.

So it’s continuing to check in with them and working with them around those things and continuing to check in on their mood and in particular what you’re looking for is you know, are we starting to see a reduction in the frequency and the intensity of the symptoms that they are reporting and how much is it impacting upon their ability to get on and do those things yeah those responsibilities that they have so that functioning can they do what they’re required to do socially in their family interpersonal relationships in their work context as well.

Nicole, that’s really comprehensive and really helpful so thank you very much for that.

For people who are listening to this if you’re interested in exploring more of the topics and points that Nicole was discussing with us there’s some really good resources and materials and recommended references on the page.

Thanks very much for your time Nicole.

Nicole: Thanks Leanne. Thank you.