Prevalence and Predictors of Mental Health Distress Post-Katrina: Findings From the Gulf Coast Child and Family Health Study David Abramson, PhD, MPH, Tasha Stehling-Ariza, MPH, Richard Garfield, RN, DrPH, and Irwin Redlener, MD ABSTRACT Background: Catastrophic disasters often are associated with massive structural, economic, and popu- lation devastation less understood are the long-term mental health consequences. This study mea- sures the prevalence and predictors of mental health distress and disability of hurricane survivors over an extended period of recovery in a postdisaster setting. Methods: A representative sample of 1077 displaced or greatly affected households was drawn in 2006 using a stratified cluster sampling of federally subsidized emergency housing settings in Louisiana and Mississippi, and of Mississippi census tracts designated as having experienced major damage from Hurricane Katrina in 2005. Two rounds of data collection were conducted: a baseline face-to-face interview at 6 to 12 months post-Katrina, and a telephone follow-up at 20 to 23 months after the disaster. Mental health disability was measured using the Medical Outcome Study Short Form 12, version 2 mental component summary score. Bivariate and multivariate analyses were conducted examining socioeconomic, demographic, situational, and attitudinal factors associated with mental health distress and disability. Results: More than half of the cohort at both baseline and follow-up reported significant mental health distress. Self-reported poor health and safety concerns were persistently associated with poorer mental health. Nearly 2 years after the disaster, the greatest predictors of poor mental health included situational characteristics such as greater numbers of children in a household and attitudinal char- acteristics such as fatalistic sentiments and poor self-efficacy. Informal social support networks were associated significantly with better mental health status. Housing and economic circumstances were not independently associated with poorer mental health. Conclusions: Mental health distress and disability are pervasive issues among the US Gulf Coast adults and children who experienced long-term displacement or other serious effects as a result of Hurricanes Katrina and Rita. As time progresses postdisaster, social and psychological factors may play greater roles in accelerating or impeding recovery among affected populations. Efforts to expand disaster recovery and preparedness policies to include long-term social re-engagement efforts postdisaster should be considered as a means of reducing mental health sequelae. (Disaster Med Public Health Preparedness. 2008 2:77���86) Key Words: mental health, social-ecological model, longitudinal cohort, Hurricane Katrina Devents eveloping countries routinely experience mass disasters as a consequence of natural weather or of social or political conflicts, and the consequences are often compounded by social vulnerabil- ities and inadequate infrastructure and lifelines. The United States is unaccustomed to dealing with socially seismic events. In particular, disasters that displace large numbers of people or that destroy significant amounts of housing stock or critical infrastructure are relatively rare. The 2005 hurricanes Katrina and Rita represented such rare domestic events. Combined, they affected an area of 108,000 mi2, displaced nearly 500,000 people, and exacted an economic cost estimated at more than $130 billion. In the aftermath of these hurricanes, several research efforts described the immediate impact of the disaster on affected populations. Virtually all of the field reports noted the incidence of acute mental health problems among survi- vors of the disaster.1���5 Less well understood are the long- term health and psychological effects of the disaster on affected populations. Recent commentators have high- lighted the growing concerns surrounding mental health needs subsequent to such natural and manmade disasters.6 Scholars have long distinguished between the pri- mary effects of the disaster event itself and the sec- RESEARCH Disaster Medicine and Public Health Preparedness 77

ondary effects of postdisaster phenomena such as a popula- tion���s long-term displacement or the consequences of particular recovery policies and programs.7 In the case of the 2005 Gulf Coast storms, the secondary effects included un- stable housing, hazardous and crowded housing conditions, loss of social institutions and social networks, and degraded civic infrastructure, particularly among the education, health care, and criminal justice systems. Much of the secondary effect may be attributable to the large-scale population dis- placement. The Census Bureau projected that as of Decem- ber 2005 approximately 447,827 individuals had been dis- placed from the affected areas of Louisiana and Mississippi, among whom were 163,106 children under the age of 18 years.8 Of these nearly half-million individuals, approxi- mately 80,000 were placed in transitional housing settings such as group trailer homes or hotels, and an additional 200,000 were given trailers by the US Federal Emergency Management Agency (FEMA), which were placed on their private property. The remaining 170,000 individuals either resettled out of state or found housing in the private market elsewhere in the state. (Transitional housing estimates are based on data from the FEMA Gulf Coast Recovery Office that a total of 21,860 trailers and mobile homes were sited in group settings such as FEMA-developed group sites or preex- isting commercial trailer parks in Louisiana and Mississippi, approximately 10,000 units were secured in hotels and mo- tels, and an additional 102,774 trailers and mobile homes were sited on private property.9 The population was esti- mated as 2.5 individuals per group site or hotel room and 2.1 per private site.) Recent conceptualizations of community resilience in the face of disasters have focused on the capacity of individuals and communities to adapt to and survive major shocks and stresses,10 and consistent or improved mental health postdi- saster may serve as a marker of such adaptation. Using the Medical Outcome Study Short Form-12 (SF-12) mental health component summary score, this study measured the prevalence of mental health disability among a displaced or heavily affected postdisaster population over 2 points of time, and further examined the factors associated with positive or negative mental health outcomes. METHODS A stratified cluster sampling strategy was used to enroll sub- jects in the study in 2 phases: the first was used in Louisiana in February 2006, the second in Mississippi in August 2006. Using lists of congregate housing sites obtained from FEMA, we stratified the lists by type of site (FEMA group sites, commercial trailer sites, and hotels) and by size (1���25, 26��� 50, 51���100, 101 residential units). Congregate sites were selected within each substratum using a probability propor- tional to size strategy without replacement. Overall, 26 sites were selected as primary sampling units: 12 FEMA group sites, 10 commercial trailer sites, and 4 hotel sites. In addition to sampling the displaced population living in congregate settings, we supplemented the sample frame in Mississippi with an areal sample. Using FEMA damage assessment maps and databases of the state���s 3 coastal counties hardest hit by the hurricane, the team randomly selected 150 of 650 census blocks (primary sampling unit clusters) that had been char- acterized by FEMA as having sustained moderate, extensive, or catastrophic damage. As illustrated in Table 1, 4284 households were sampled as secondary sampling units. Of those, 985 households were deemed ineligible because they were clearly destroyed, vacant, abandoned, or under con- struction, leaving 3299 eligible households. Among those, 1587 households had an eligible adult present to whom the study was presented at the remaining 1712 households, no contact was made despite repeated efforts. Among the 1587 contacted households, 1077 agreed to be enrolled in the longitudinal study, corresponding to a response rate of 32.6% (1077/3299) and a cooperation rate of 67.9% (1077/1587). A bias analysis was conducted to identify significant differences between respondents who agreed to be studied longitudinally and those who did not. Individuals who did not report their TABLE 1 Sampling Response and Recruitment Rates Louisiana Mississippi Total No. of sampled households 1600 2684 4284 No. ineligible at baseline 0 985 985 Total eligible 1600 1699 3299 No. of households no response/no contact 781 931 1712 No. contacted 819 768 1587 No. agreed to follow-up, and interviewed 553 524 1077 No. agreed to baseline only, and interviewed 114 56 170 No. not available 41 128 169 No. refused 111 60 171 Response rate for longitudinal study (agreed to follow-up/total eligible), % 34.6 30.8 32.6 Cooperation rate for longitudinal study (total interviewed/contacted), % 67.5 68.2 67.9 Cooperation rate for baseline study (interviewed/contacted), % 81.4 75.5 78.6 Refusal rate (refused/contacted), % 13.6 7.8 10.8 Mental Health Needs Post-Katrina 78 Disaster Medicine and Public Health Preparedness VOL. 2/NO. 2