César A. Alfonso, MD

Everyone in Puerto Rico (PR) was affected by Hurricane Maria, which made landfall on September 20, 2017 as the largest scale natural disaster in the US during our lifetime. Many months later, Puerto Ricans continue to face unreasonable obstacles that prevent recovery. This article summarizes literature on post-disaster mental health and describes the public health crisis in PR. Special attention is given to highlight higher suicide rates and PTSD that develop in post-disaster areas.

Psychosocial context and obstacles to recovery

A country with a high-income economy, PR experienced financial decline a decade before Hurricane Maria. A recession and high unemployment rates led to a depopulation process. From 2006 to 2016 the population decreased from 3.9 to 3.4 million.

 Migratory flow during the economic crisis resulted in compromised provision of essential services and a large exodus of medical professionals. Homicide and suicide rates nearly doubled and binge drinking increased. Approximately 50% of adults in PR are binge drinkers compared with the US national average of 17%.

Currently, 45% of the island residents live in poverty. Hurricane Maria caused an estimated $100 billion in damages.

 Four months post-impact 32% of the population had no electricity and 14% had no potable water.

 The official death toll has been questioned, and physicians acknowledge an increase in unreported deaths of vulnerable persons because of inadequate access to medical care.

Mr. S is an elderly man from PR who now lives in the continental US. He has sarcoidosis, diabetic retinopathy, and blindness. He is being treated for PTSD after early childhood trauma and adult retraumatization from domestic violence. Mr. S reports to his psychiatrist that his brother had died in PR 3 weeks after the hurricane. He had been in adequate health but was oxygen dependent, after the hurricane he lost access to medical equipment and died of suffocation. Mr. S, in acute grief, was conflicted about attending the funeral. As a brittle diabetic, he feared that his health would be compromised if he went to PR. With no electricity or potable water, refrigeration for his insulin would be impossible. Encouraged by his family and physicians, he decided not to attend funeral services and instead held a memorial mass in memory of his deceased brother.

A conversation with Natalio Izquierdo, Past President of the PR Medical Association, confirms that unreported deaths due to delayed access to care have surpassed media estimates. Izquierdo, an ophthalmologist, coordinated with medical centers in the US for emergency transfers using Air Force planes to import essential supplies and transport patients needing urgent interventions. Puerto Rican physicians have made heroic efforts on behalf of their patients, but many hospitals, ambulatory care centers, dialysis centers, chemotherapy infusion centers, radiation oncology suites, operating rooms, and doctors’ offices remain inaccessible or unable to maintain adequate levels of care.

An excerpt from a journal entry of a resident of PR illustrates the situation in PR post-hurricane [Anonymous, shared with author 2017].

My immediate reaction to the hurricane was to check in with relatives to ensure they were safe. This took several days as communications were down and roads were blocked with fallen trees and debris. We began to learn the severity of damages through scattered news reports. I stayed disconnected from my mother, who lived merely 30 miles away, for several days. She lives alone and I feared for her wellbeing. Eventually we made contact and I was relieved to find out she was uninjured, but I felt guilty that I could not help others who experienced loss. Anxiety grew. I had poor concentration, erratic sleep, distressing dreams and was startled when hearing sirens or gunshots at night. Agitation and anxiety would alternate with apathy, withdrawal, and numbness. Some symptoms improved but I struggle to stay motivated and productive. Debris still line the streets, some towering as high as homes. Homes have shattered or boarded up windows and parts of the roof missing, and traffic lights at intersections are down or dangling on wires. One of the hardest realizations was that recovery from this hurricane would not take months, but years. This was a rude awakening to the vulnerability of the very institutions that are expected to be able to respond in situations such as these. Hope waxes and wanes.

Economic losses following natural disasters compound physical destruction and health outcomes. A study following typhoons in the Philippines found that household income drops and infant mortality rises the year after a typhoon hits, and economic deaths by far exceed exposure deaths, by a factor of 15.

New Orleans lost 44% of its population a year after Katrina, and unemployment rose to 33%.1 Will PR be faced with a similar exodus and economic downturn? Experts estimate that by 2019, PR will lose an additional one-half million residents. Physicians and other health professionals are relocating to the continental US in large numbers. William Julio, from the Puerto Rican Psychiatric Society, reports that the number of psychiatrists in the island decreased from 500 to 300 over the last decade.

Although suicide rates vary depending on the location and population studied, we see that suicidal behavior increases following natural disasters. In PR there was an average of 19 suicides per month in the 8 months before Maria in 2017, and 25 suicides per month in the immediate 3 months post Maria (

Kessler and colleagues6 noted significant increases in the prevalence of suicidal ideation and suicide plans 6 months post-hurricane Katrina compared with 2 years later. They concluded that follow-up outcomes persist and even intensify because psychosocial stressors associated with the natural disaster continue or intensify as time progresses.

From a psychodynamic standpoint one could formulate that dissociation, reaction formation, and heroic efforts that occur soon after a disaster serve as protective factors against suicide, but these defenses only offer temporary relief as the grim reality of destruction and loss evolve into complex affective states of disillusionment, hopelessness, and helplessness. These complex states of mind correlate with high suicide risk and may explain the protracted post-disaster increase in suicide deaths.

The literature on PTSD after natural disasters is extensive. Neria and colleagues

 undertook a comprehensive review of the relationship between man-made compared with natural disasters and PTSD in survivors between 1980 and 2007. Findings from the survey indicate PTSD prevalence among direct victims of disasters of 30% to 40% compared with a prevalence of 5% to 19% in the general population. PTSD determinants include sociodemographic and background factors, event exposure characteristics, social support factors, and personality traits.

A study of Florida residents exposed to Hurricane Andrew in 1992 found that the prevalence of PTSD increased to 26% and 29% at 6 and 30 months after the disaster.

 A specific finding of this study was that while intrusion and arousal symptoms declined over time, avoidance symptoms increased. Variables found to be predisposing factors in this study included specific populations at risk (eg, minorities, elderly, children, direct victims, first responders), persons who bear the brunt of the social and economic consequences, and the magnitude of exposure to the event. Particularly, degree of physical injury, immediate risk of life, severity of property destruction, distance from epicenter, people who experienced loss of family members, and people who suffered property loss or were forced to relocate were at higher risk for PTSD. Additional risk factors for PTSD after hurricanes and other natural disasters are listed in Table 2.

Blackouts and power outages post-disaster negatively affect mental health. Studies after Hurricane Sandy, which caused outages lasting up to 2 weeks, found a dose-response relationship between the quantile of maximum blackout percentage and the risk of mental health problems.

 Mood disorders, anxiety disorders, substance use disorders, and utilization of psychiatric resources in the New York area increased for months to a year after Hurricane Sandy.

Sub-threshold PTSD, common in post-disaster states, results in significant morbidity. In Louisiana, previously considered a permutation of generalized anxiety disorder (GAD) colloquially became known as “Katrina brain.” Many Katrina survivors with GAD described additional symptoms of irritability, diffuse anger, guilt, and health worries.

After the September 11 terrorist attacks, researchers at the New York State Psychiatric Institute studied the morbidity of sub-threshold PTSD among disaster survivors and found increased suicide rates of sub-threshold PTSD, even after controlling for MDD.

With little economic relief in sight in the foreseeable future, approximately a million Puerto Ricans are expected to present with PTSD in the next 2 years and hundreds will die by suicide as a result of the hurricane. We hope that this article will serve to clarify protracted disaster-related psychopathology, especially within the context of psychosocial and economic stressors. In addition we hope heighten awareness among members of the World Psychiatric Association and American Psychiatric Association, at institutional-systemic and national-local levels, to offer assistance to those affected by this humanitarian crisis.

 is Associate Professor of Psychiatry, Columbia University Medical Center, and Chair, Psychotherapy Section of the World Psychiatric Association.

Dr Alfonso reports no conflicts of interest concerning the subject matter of this article.

 Melendez E, Hinojosa J. Estimates of Post-Hurricane Maria Exodus from PR; October 2017. 

https://centropr.hunter.cuny.edu/research/data-center/research-briefs/estimates-post-hurricane-maria-exodus-puerto-rico

 NIH-NIAAA. Alcohol and the Hispanic Community; 2015. https://pubs.niaaa.nih.gov/publications/hispanicfact/hispanicfact.htm. Accessed February 23, 2018.

 Coto D. Murders in Puerto Rico surge as Hurricane Maria recovery continues. Time Magazine. January 11, 2018.

 FEMA. Hurricane Maria. https://www.fema.gov/hurricane-maria. Accessed February 23, 2018.

 Preliminary Statistics of Cases of Suicide in Puerto Rico, January to November 2017[in Spanish]. 

http://www.salud.gov.pr/Estadisticas-Registros-y-Publicaciones/Estadisticas%20Suicidio/Noviembre%202017.pdf

 Kessler RC, Galea S, Gruber MJ, et.al. Trends in mental illness and suicidality after Hurricane Katrina. Mol Psychiatry. 2008;13:374-384.

 Neria Y, Nandi A, Galea S. Post-traumatic stress disorder following disasters: a systematic review. Psychol Med. 2008;38:467-480.

 Norris FH, Perilla JL, Riad JK, et al. Stability and change in stress, resources, and psychological distress following natural disaster: findings from Hurricane Andrew. Anxiety Stress Coping. 1999;12:363-396.

 Lin S, Lu Y, Justino J, et al. What happened to our environment and mental health as a result of Hurricane Sandy? Disaster Med Public Health Prep. 2016;10:314-319.

 Marshall RD, Olfson M, Hellman F, et al. Comorbidity, impairment, and suicidality in subthreshold PTSD. Am J Psychiatry. 2001;158:1467-1473.

Articles

This article summarizes literature on post-disaster mental health and describes the public health crisis in Puerto Rico. Special attention is given to highlight higher suicide rates and PTSD that develop in post-disaster areas.

PTSD and Suicide After Natural Disasters

Nonadherence to treatment by patients represents one of the most prevalent and important challenges to the practice of psychiatry. Despite treatment advances and efforts to elucidate the determinants of noncompliance to medical care, nonadherence remains ubiquitous in persons with chronic medical conditions (with average adherence rates of 43% to 78%) and in psychiatric cohorts (with average adherence rates of 50% to 62%).

 Researchers in cognitive-behavioral therapy, psychoeducation, and motivational interviewing have made significant contributions to understanding nonadherence and tailoring interventions to improve treatment adherence.

 A psychodynamic theoretical framework is another approach to understanding and improving adherence.

Psychodynamic theory is a framework that could be helpful in clarifying our understanding of nonadherence. In particular, looking at the contributions of attachment theory and research has allowed us to deepen our understanding of nonadherence.

 Strengthening the therapeutic alliance and fostering collaborative physician-patient relationships may result in improved adherence.

Psychological and psychodynamic antecedents of nonadherence

have written extensively on the connection between early childhood trauma and nonadherence or resistance to care in adult patients with posttraumatic stress disorder and comorbid depression. They postulated that traumatized patients’ sense of a foreshortened future may be related to failure to engage in or accept medical treatment, which suggests that early childhood trauma is a psychological risk factor for adult nonadherence.

Psychodynamic determinants and adaptive (and maladaptive) defenses related to nonadherence in psychiatric patients include

• Denial, rationalization, and isolation of affect

• Feeling coerced, disrespected, or infantilized by the physician

• Sensing that the psychiatrist is tentative or ambivalent when presenting the information

As prescribers, our failure of empathy often stems from an unconscious need to feel separate from our patients-to defend ourselves against overwhelming distress and maintain a safe space and emotional distance-consequently, abstinence and neutrality are overemphasized.

 A collaborative stance promotes adherence, while paternalistic or categorical medication advice could be perceived as coercive and could result in partial or nonadherence.

A recent focus on the interface between attachment theory and psychoanalytical theory has deepened our understanding of the psychodynamics of nonadherence. Attachment theory is based on the premise that early life experiences with caregivers are internalized and determine how individuals relate to others in adulthood. Attachment concepts were originally conceived to understand the evolutionary, adaptive, and biological aspects of parent-infant care giving. Most recently, clinical research has validated the usefulness of attachment concepts in understanding nonadherence.

The disruption in attachment bonds by separation, rejection, loss, inconsistent attunement, or fear can lead to problematic behavior during childhood and possibly across the life span. Research has demonstrated that the caregiver’s sensitivity to the infant’s needs (availability and responsiveness) is essential to ensure secure attachments and lead to an empirically based classification of mother-infant dyads.

What is already known about the psychodynamics of nonadherence? 
? Classical psychoanalytic theory, with emphasis on concepts of resistance, transference, and countertransference, has shed some light and guided clinicians who work with patients who are nonadherent. Some helpful psychodynamic concepts include clinicians’ failure of empathy that stems from an unconscious need to feel separate from our patients’ distress, and their use of defenses of denial, rationalization, and isolation of affect.

What new information does this article add? 
? In this article, emphasis shifts to understanding nonadherence using the paradigm of attachment theory.

What are the implications for psychiatric practice? 
? Identifying adults with dismissing attachment style can be predictive of nonadherence to care. Dismissing individuals are compulsively self-reliant and tend to idealize or devalue with facility, but they can be easily engaged in psychotherapy and are open to the possibility of “earned attachment” through collaborative, nonconfrontational psychotherapeutic interventions.

 observed in their laboratories infants’ reactions to separation from the mother, exposure to a stranger, and reunion with the mother. They initially described 3 types of attachment interactions: secure, avoidant, and ambivalent. Secure infants are consoled by reunion and reconnection with the mother; infants with avoidant attachment are indifferent and avoid the mother when reunited; and infants with ambivalent attachment, although preoccupied with the mother’s whereabouts during separation, are inconsolable during reunion. Secure infants have sensitive and attuned parents; avoidant infants have parents who are emotionally constricted and uncomfortable with physical contact; and ambivalent infants have parents who oscillate in their stance from available and responsive to insensitive and rageful.

 reports that a level of consistency was found between behavior observed in infancy and attachment styles in adulthood in up to 75% of subjects studied longitudinally. More important, research has demonstrated that many adults with histories that would predict insecure attachment behaviors have reparative experiences later in life with significant others that allow for “earned secure” attachments. Sensitivity, availability, and responsiveness are at the core of all psychotherapeutic interventions and enduring life-enhancing relationships.

 examined correlations between attachment styles and treatment adherence and hypothesized that certain adult attachment styles correlate with treatment adherence in the medically ill. They studied cohorts of diabetic patients in primary care clinic settings, a high-risk population because nonadherence to treatment among diabetic patients is associated with significant morbidity and mortality. The initial hypothesis was that only those with secure attachments would be treatment-adherent. However, the findings were surprising and indicate that 1 attachment style correlates with nonadherence, 1 correlates with adherence, and 2 are not significant. They found that persons with dismissing attachment style had significantly worse glucose control than those with secure, preoccupied, or fearful attachment styles.

Dismissing individuals, such as infants who do not protest when separated from parents and who are indifferent to their return and are inhibited at play, as adults become compulsively self-reliant and are uncomfortable being close to or trusting of others. Narratives of dismissing individuals are characterized by a very brief discourse, gross generalizations, a paucity of examples, unsupported claims (even active contradictions), and an insistence on absence of childhood memories. They idealize or devalue one or both parents but are usually unable to substantiate their claims.

Adults with secure attachment experienced consistently responsive caregiving parents, while adults with dismissing attachment had avoidant parents who were consistently emotionally unresponsive. Adults with secure attachment are comfortable depending on others and are readily comforted by them. Adults with dismissing style become compulsively self-reliant, describe themselves as independent and self-sufficient, and are uncomfortable being close to or trusting of others. Dismissing patients, while initially unable to remember, describe, emote, or reconstruct experiences, can be gradually exposed to these processes by a psychodynamically informed therapist.

Awareness of dismissing attachment behaviors in our nonadherent patients can help us reframe our psychotherapeutic work. Wallin

 describes the process of therapeutic interventions with dismissing individuals as “moving from isolation to intimacy.” In the early stages of treatment, he encourages a keen awareness of subtle affective cues and nonverbal communication, and judicious sharing of coun-tertransference, to help patients be comfortable in letting others in and in being treatment collaborators.

The dynamics of power struggles and control need to be clearly understood by the therapist, and a warm, collaborative, and cooperative stance is preferred to an authoritarian and detached attitude. Attachment theory and research provides a useful framework for understanding the impact of parent-infant caregiving on development and subsequent adult patterns of relationships. Psychotherapy interventions based on attachment theory for parents with insecure caregiving styles can promote parental sensitivity and secure attachment organization. Similarly, psychotherapy interventions informed by the contribu-tions of attachment theory could help adults with dismissing attachment behaviors who are nonadherent to treatment by stressing the importance of collaborative relationships, relinquishing excessive self-reliance and control, and promoting trust.

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 Nonadherence to treatment by patients represents one of the most prevalent and important challenges to the practice of psychiatry. 

Author | César A. Alfonso, MD

Articles

PTSD and Suicide After Natural Disasters

Understanding the Psychodynamics of Nonadherence