Hurricane Katrina’s swath of devastation extends far beyond the Gulf region to the psyches of hundreds of thousands of evacuees flung coast to coast.

With mental health resources ever-limited and masses of people profoundly affected, nurses will face a crucial challenge: figuring out who most needs help and deciding what will help most.

Perhaps a third of the people hardest hit by Katrina could develop posttraumatic stress disorder, research suggests. In the aftermath of 1992’s Hurricane Andrew, one study found, 36% of South Florida subjects highly exposed to the disaster met criteria for new-onset PTSD six months after the storm, while 30% suffered major depression. In addition, more than half of the sample had significant psychiatric symptoms that lasted longer than six months.¹

Disaster-related mental ills also come in the form of anxiety disorders, exacerbation of existing substance abuse problems, and somatic complaints.²

“You want to evaluate each individual, which can seem like an overwhelming task,” advises crisis interventionist and mental health researcher Ann M. Mitchell, RN, PhD, assistant professor of nursing at the University of Pittsburgh’s School of Nursing. “You want to think in terms of crisis exposure, including proximity and duration, and then to think in terms of what the survivors’ relationships are to other crisis victims” — for instance, if someone lost family members.

Worst kind of disaster

The people who lived through Katrina know it was the worst kind of disaster. Mental health experts know, too.

Research has identified four keys to gauging the mental health impact of such events, any two of which will engender “severe, lasting, and pervasive psychological effects.”³ Katrina involves three: extreme and widespread property damage, serious and ongoing financial problems for the community, and high prevalence of trauma in the form of injuries, threat to life, and loss of life. (The fourth factor is when human carelessness or, especially, human intent caused the disaster.)³

Who’s at highest risk

The severity of a person’s exposure to the tragedy represents perhaps the single biggest contributor to risk of psychological trauma, experts note. Relevant factors include bereavement, injury to self or a family member, threat to life, panic during the disaster, horror, separation from family (especially for youngsters), extensive loss of property, and relocation or displacement. Worse, these factors pile up: The more exposures that people have experienced, the more likely they are to suffer psychological impairment.⁴

A pre-disaster history of psychiatric illness is another significant risk factor. “We want to identify those with chronic mental illness because they have another whole set of issues to be coped with, including safety and medication management,” Mitchell says.

Other circumstances also elevate risk, studies have found. For instance, females are more likely than males to suffer psychological harm from disaster, with PTSD rates twice as high for women as for men.

Catastrophe can also widen socioeconomic divides. People who are poor, not well-educated, less literate, or who hold low-status jobs appear more likely to suffer distress in the wake of disaster. Ethnic minorities are particularly vulnerable. And adults ages 40 to 60 — with greater stress and burden than those older or younger — may be especially at risk for psychological problems.

The degree of their parents’ mental trauma may be the best predictor of children’s ills. In fact, experts say providing support to severely distressed parents may be one of the most effective ways to support children.⁴

What to watch for

Nurses first need to evaluate an individual’s potential danger to self or others. Second, nurses need to know the symptoms of PTSD and the resources that are accessible to people who need them, Mitchell says. Among the symptoms for which to be vigilant are re-experiencing of the trauma (such as nightmares, flashbacks, intrusive thoughts); increased arousal (restlessness, sleep disturbance, heightened startle reactions, angry outbursts); avoidance of reminders of the trauma (isolation from family or friends, emotional numbness, prolonged fatigue). Other important symptoms are a sense of helplessness or hopelessness, severe time distortion, and/or traumatic amnesia.

Evidence suggests disaster survivors most at risk for emotional problems believe others don’t care about them, they have little control over their fate, or they have few internal resources to manage stress.⁵

On the other hand, survivors’ belief that they have the capacity to cope appears more important than their actual methods of coping. In fact, it may be prudent for caregivers to focus more on reassuring people they have what it takes to endure the trauma than teaching particular coping strategies.⁴

Over the long term, research has found, survivors most likely to suffer are those who already were under a great deal of stress or who have few social or personal reserves from which to draw strength.

“People who don’t have a lot of resources, either family, social, or community — these are the people who are going to be most vulnerable,” Mitchell says.

How an individual ultimately responds to a crisis depends on personality, perception of threat, and past and current coping skills, Mitchell says, noting, for example, that the presence of a religious or spiritual belief system during times of crisis can be an important coping resource.