"Unlike the physical damage which is all too obvious, the psychological toll will have effects that cascade over time," Dr. Octavio N. Martinez Jr., executive director of the Hogg Foundation for Mental Health at the University of Texas at Austin, wrote in an email.
Most of those affected by these intense storms are functioning as normal, with symptoms that may not seem very serious: anxiety, difficulty sleeping, sadness. Most notice their symptoms yet accept them as part of the impact of the disaster.
"It is when these symptoms affect the person's ability to function when it becomes crucial to reach out for assistance," Martinez wrote. After all, distress behaviors -- such as feelings of marginalization, increased smoking and alcohol use, and chronic irritability -- have a tendency to slip under the radar, he said.
Katrina and Sandy
For example, the prevalence of post-traumatic stress disorder (PTSD) in Alabama, Louisiana and Mississippi rose from 15% a few months after Katrina to 21% a year later, Martinez noted, based on the study. PTSD
is a mental health disorder that develops in some people who have experienced a shocking or dangerous event.
"And the percentage of people experiencing suicidal thoughts more than doubled from 2.8 percent to 6.4 percent," Martinez wrote.
Meanwhile, other studies
have indicated that traumatic events during childhood can have a lasting life impact by increasing a child's future risk of smoking, using alcohol and substances, obesity, depression, heart disease, cancer and even early death.
"This will be especially relevant to children and youth who endured Hurricanes Harvey and Irma," Martinez said.
Rebecca M. Schwartz, an associate investigator at the Feinstein Institute for Medical Research in Manhasset, New York, looked at the mental health impact of Hurricane Sandy among adults living in some areas of Queens, Staten Island and Long Island. The study
included a simple 30-item survey with participants checking off whether they'd experienced damage to their homes, damage to their cars and displacement. They also answered whether they felt their lives had been endangered or if a family member went missing.
"Basically, increased exposure to the hurricane -- the more events or the more things that happened to you during Hurricane Sandy -- the more likely you were to experience higher levels of depression symptoms, anxiety symptoms, perceived stress, and PTSD symptoms," Schwartz said.
Displacement, in particular, was linked to developing symptoms of PTSD, she said. People who stayed at a temporary shelter, for example, were more at risk for PTSD than those who boarded with friends or family.
Sarah Lowe, an assistant professor of psychology at Montclair State University in New Jersey, has also investigated the psychological aftermath of natural disasters. For one study of resilience
, she and her colleagues interviewed survivors of Hurricane Katrina about their mental health, their social relationships, and how the hurricane contributed to changes in their lives one year, three years and 12 years later.
"The punch line is that most people are very resilient to disasters," Lowe said.
"If you look a year out, there's only going to be a small percentage of survivors who meet criteria for mental disorders, such as PTSD and major depressive disorder," Lowe said.
Jeff Temple, a professor at University of Texas Medical Branch, said that in the immediate aftermath of a disaster, many people will experience symptoms, and yet their ranks dwindle as time passes.
"Right away, the first month, if the symptoms are to a high degree or worrisome, that's when we would diagnose acute stress disorder," he said. And if the symptoms persist longer than a month, that's when PTSD might be diagnosed.
Jesse Cougle, associate professor of psychology at Florida State University, said Hurricane Irma did little damage to Tallahassee, where he teaches, compared with Miami and the Keys, and widespread evacuations in Florida served as a protective buffer.
The people who stayed and witnessed the destruction will probably experience worse mental health than those who evacuated, he said. Still, it's possible, Cougle said, that even those who evacuated will experience symptoms in the days to come. Finding a place to flee to in heavy traffic was highly stressful, and "negative life events can trigger these types of reactions," Cougle said.
"Of course, what makes hurricanes different than a lot of other traumatic events, too, is if your property is damaged," he said. "A lot of people can become homeless, a lot of people can be thrown off from normal healthy routines they have, and there's just all this stress associated with repairing their house, repairing their property and just kind of adapting to all the problems."
Capt. Maryann Robinson, chief of emergency mental health and traumatic stress services branch at the Substance Abuse and Mental Health Services Administration
, said that "when you go home and now you are actually faced with what has happened -- the devastation that has occurred in your home -- it really does re-traumatize the individual."
Still, Robinson said, "not everyone is going to need treatment. Most people do pretty well on their own."
Some even find an unexpected silver lining in the storm clouds.
Lowe, of Montclair State University, and her colleagues looked at patterns of distress one year pre-Katrina and again at both one year and three years after
the storm in a separate study
of the hurricane's effects.
"For about 5% of participants, their mental health actually improved," Lowe said. "They had severe distress prior to the storm and then afterward were indistinguishable from people we would call resilient -- who maintain low levels of distress." Another group also had severe distress prior to Katrina, but one and three years after the storm, they had lower levels than before the storm but only slightly elevated above average.
The trauma of a natural disaster, then, actually improved the mental health of some people -- a phenomenon Lowe calls post-traumatic growth.
The reasons are unclear.
"So maybe before the storm, they had experienced many stressful and traumatic life events -- such as childhood abuse, sexual abuse, intimate partner violence -- and the hurricane was the first time where they came in contact with mental health services where they could deal with pre-existing vulnerabilities," Lowe said.
For others, the displacement and subsequent relocation to new areas allowed them to "seize upon new opportunities, whether it be educational opportunities, employment or new opportunities for relationships," Lowe said. Some said they were able to get away from problematic relationships by being in a new community, while for others, the displacement allowed their children to enroll in new, better-quality and more diverse schools.
Post-traumatic growth is "an intuitive phenomenon," Lowe said, in which some people find they've grown as a person "whether it be that they feel stronger, or they feel they can see new possibilities in their lives, or their relationships got better, or they have a stronger connection with God or spirituality."
Post-traumatic growth often walks hand-in-hand with symptoms of PTSD: The adults who grew most had some of the worst psychiatric responses, Lowe said.
Still, not all PTSD sufferers experienced growth.
Who is at risk?
Women are more vulnerable to PTSD than men after disasters, Lowe said.
"In general, people who have fewer resources -- so lower levels of social support, lower income -- tend to be more vulnerable," she said. "As well as racial and ethnic minorities."
Robinson added that children and the elderly are also more vulnerable.
"Cumulative exposure also serves as a precursor" to PTSD, Robinson said, so people who have had past traumatic experiences will be more susceptible to stress.
Even first responders, who help others in dire circumstances, can succumb to symptoms of anxiety and depression after a natural disaster, Robinson said: "If you are not processing the things that you see in a very healthy way, you are at more risk for a long-term consequence."
Temple said that a lot of the mental health issues following a natural disaster stem from "direct exposure" to being in danger and seeing other people imperiled.
"So some of those at the epicenter of the disaster are certainly going to be the most vulnerable to mental health problems," Temple said. However, people throughout the Houston area and even nationally felt distress just by seeing images from the 24/7 news cycle, he said. Whether images of a disaster are viewed on social media or television, Temple said, it is usually those who have already experienced previous traumas who will succumb to distress.
As Martinez, of the Hogg Foundation for Mental Health, noted, "It's been said that time heals all wounds, but there's reason to doubt that truism."
What to do?
"There are resources for mental health support that we're encouraging people to use, and our organization has compiled a modest list of them
," Martinez noted. "There is no silver bullet, but these are excellent places to start."
"Everybody feels sad at times, and that's normal but when you've been through a trauma. It's OK to seek help," Schwartz said. After Sandy, people who normally did not experience mental health difficulties were very quick to dismiss their symptoms, she said. With a house needing repair, insurance papers to file, "they pushed their health and mental health to the back burner," she said.
"If you're feeling stressed, if you're feeling overwhelmed, the best thing you can do is to seek help. If you do not, all the other things that need to be dealt with ... become impossible to do if you're depressed and anxious and suffering from PTSD symptoms," Schwartz said.
Even four years later, time had not dispelled the symptoms for some.
"We did see some amazing ... community work being done, where people were meeting in groups and sharing their experiences," Schwartz said. Still, she advised professional help and said that mental health should be prioritized "just like you would any other aspect of recovering from these hurricanes."
Cougle said there are important things to do -- and not do -- to help the natural adaptive process or resilience possessed by most people.
"One is, realize that anxiety is just a normal response to the hurricane and having to evacuate and all the stress and uncertainty associated with that," Cougle said. "It's the survival instinct. It's not dangerous to feel anxious in that way."
Still, he added, people should "resist the urge to cope with or avoid anxiety with things like substance use.
"Social support is a pretty well-established buffer against the development of PTSD following a trauma," Cougle said.
Temple suggested "getting back to a normal routine. Your brain is rewired, basically, when you experience this sort of traumatic event, so give yourself some semblance of what it used to be like and have some of that normal routine."
After a disaster, a rare few feel no anxiety and then worry about this reaction.
"It's OK to not have a reaction at all," Temple said, but it also "doesn't mean you're immune to later effects. You can be perfectly fine and then a month later develop PTSD." (Usually, PTSD develops within six months
of a trauma. With longer delays, doctors suspect the sufferer did not notice their symptoms.)
"So being continually on guard for changes -- changes in behavior, changes in mood -- both in yourself and friends and family members is good," Temple said.
Sleep and exercise
"We tell people to pay attention to your physical self," the Substance Abuse and Mental Health Services Administration's Robinson said, "so make sure you're getting enough sleep and you're resting."
It's important for survivors to guard their health by eating nutritious meals, exercising and avoiding "caffeine, tobacco, drugs and alcohol," she said.
"We tell people to move," Robinson said. "It just may be walking around and taking deep breaths. Taking deep breaths really does serve as a purging. It helps to move stress out of the body."
Relaxing music can also help, she said.
Many people have mental health skills they developed when, say, a parent died or illness made an appearance, she said: In the aftermath of a natural disaster, you must bring to bear all the coping skills that helped you in the past.
She also suggests calling her agency's Disaster Distress Helpline at 800-985-5990
"We have crisis counselors that are manning the phone 24/7, seven days a week, 365 days a year, for those individuals who are experiencing stress, distress, emotional, anxiety and depression," Robinson said.
With responses translated into over 100 languages, anyone and everyone can call or text the disaster helpline. A waiting counselor will offer tips for managing your mental health symptoms and steer you to available community resources, she said.
"Most of which people are not aware of," Robinson said, "because before a disaster occurs, they don't need them."