It is well recognised that flooding has negative effects on mental health, particularly in people with pre-existing mental illness. ^{Reference Ahern, Kovats, Wilkinson, Few and Matthies1-Reference Oriol and Nordboe3} In this report we discuss the problems encountered by a community mental health team (CMHT) for older adults in West Oxfordshire when the population they serve suffered significant floods.

In July 2007, the heaviest rainfall for 60 years caused immediate flooding. This was followed by swelling of the rivers which then overran pre-existing flood defences. Over 200 elderly people were led to safety from nursing homes and a smaller number from private properties. An unknown number were displaced at very short notice because water damage rendered their properties uninhabitable. ⁴

Four main factors, relevant to the Oxfordshire floods, are recognised to cause psychological disturbance: immediate threat to life, displacement, damage to property and increased social isolation. ^{Reference Liu, Tan, Zhou, Li, Yang and Wang5} Worldwide, this list would also include bereavement, destruction of whole communities and water-borne disease due to loss of a clean water supply. ^{Reference Ahern, Kovats, Wilkinson, Few and Matthies1}

In this brief report we aim to describe the problems encountered by the CMHT following local floods and review what lessons can be learnt, with reference to the relevant studies.

Method

During the floods and in their aftermath the impact on patients and CMHT operations were discussed at several sequential multidisciplinary team meetings and the findings were recorded in the minutes.

Results

The experiences of the team are summarised below. They can be grouped into recognition of new mental illness, management problems, the impact on CMHT workload, and cases where there was a benefit from the flooding.

Impact of flood on patients known to CMHT and those newly referred

Of 348 individuals known to the CMHT at the time of the flood, 87 (36 male and 51 female; Table 1) lived in ‘flood affected’ areas where significant flood waters reached at least as far as their residence. ⁴ From county council data, 24 were in at least ‘moderate danger’ for their personal safety; ⁴ 7 had to be evacuated from their homes and 6 from nursing homes; 8 patients suffered significant flood damage to their property.

Table 1. Details of 87 patients who lived in flood affected areas

	Patients, n	Deterioration in mental health after flood, n
Diagnosis
Mixed dementia	24	3
Alzheimer's disease	22	0
Vascular dementia	8	0
Depression	23	4
Depression/anxiety	3	1
Schizophrenia	2	0
Mild cognitive impairment	4	0
Paranoid personality disorder	1	1
Difficulty as consequence of flood
Evacuated from nursing home	6	1
‘Moderate danger’ to personal safety1	24	5
Evacuated from private residence	7	4
Damage to property	8	6

Apart from the impact on patients already known to the CMHT, two new individuals were referred as a direct consequence of the flooding.

Emergence of new clinical symptoms

Overall, 11 clinical problems were triggered by the floods (Table 2), in ten females and one male, age range 73-90 years (mean 82). The delay in presentation of the symptoms ranged from immediate to 9 months.

Table 2. Flood induced difficulties and the clinical problems triggered in 11 individuals

Pre-flood diagnosis	Clinical problem triggered by flood	Delay from flood to presentation	Flood damage	Social isolation	Personal safety threat	Displacement
Paranoid personality disorder	Agitated depression, preoccupation with recent flood and continuing perceived risk	2 months	Nil	Lived alone with loss of recreational and social outlets as most of village flooded	No	No
Chronic mixed anxiety and depression	Acute deterioration in symptoms	1 week	Yes	Lived alone	Moderate danger	Yes (communal emergency accommodation in public building)
No mental illness	Depressive episode	9 months	Yes	Lived alone	Moderate danger	Yes (lived in holiday accommodation for over 12 months)
Recurrent depression	Flashbacks to previous evacuation experiences	1 month	Yes	No	Moderate danger	Yes
Recurrent depression	Acute deterioration in symptoms	1 week	Nil	Lived alone	Moderate danger	No
Recurrent depression	Acute deterioration in symptoms	2 weeks	Yes	Lived alone	Moderate danger	No
Recurrent depression	Acute deterioration in symptoms	1 week	Yes	No	No	No
Recurrent depression	Chronic deterioration in symptoms while waiting for damage to be repaired	9 months	Yes	No	No	No
Mixed dementia	Depressive symptoms and behavioural problems requiring admission	3 months	Yes	Lived alone	Moderate danger	Yes (moved three times as subsequent accommodation flooded after each move)
Moderate mixed dementia (undiagnosed before flood)	Standing in flood water not knowing how to respond appropriately	Immediate	Yes	Lived alone	Serious danger, no understanding of threat	Yes (in new temporary accommodation cognitive difficulties immediately apparent)
Mixed dementia and psychotic depression Yes (moved into a temporary nursing home)	Worsening of psychotic symptoms	2 months	No	No	Moderate	danger

It became obvious for one person during a rescue and subsequent care in new accommodation that they had a previously undiagnosed moderated mixed dementia. They had had no noticeable problems until they were found standing waist deep in flood water, unable to react appropriately. From the records, and results of appropriate investigations, there was no evidence to suggest that the cognitive decline had been caused by hypothermia or near drowning. One person with dementia developed problems with behavioural difficulties and depression requiring admission. This followed three moves to escape flooding. A third person with dementia suffered worsening of psychotic symptoms in response to displacement and relative overcrowding in a temporary nursing home. Five people with depression, one person with mixed depression and anxiety, and one with paranoid personality disorder suffered from new depressive symptoms, with the flood being the only recognisable trigger. Only one person was diagnosed with depression without a previous psychiatric history - symptoms emerged after 9 months of living in temporary accommodation waiting for repairs to the flooded property.

Although no cases of post-traumatic stress disorder due to these floods were noted, one person's depression worsened due to recurrence of flashbacks from childhood traumatic evacuation experiences.

Discussion

There are different forms of flooding. ^{Reference Ahern, Kovats, Wilkinson, Few and Matthies1-Reference Liu, Tan, Zhou, Li, Yang and Wang5} The most severe involve flash flooding and landslides and are most commonly associated with post-traumatic stress disorder in survivors. ^{Reference Verger, Rotily, Hunault, Brenot, Baruffol and Bard6} The psychological impact of these types of floods is comparable to that of earthquakes, volcanoes and tsunamis. ^{Reference Ahern, Kovats, Wilkinson, Few and Matthies1,Reference Phifer2,Reference Liu, Tan, Zhou, Li, Yang and Wang5-Reference Phifer, Kaniasty and Norris7} The type of flooding that affected Oxfordshire is referred to as ‘water soaking’ and triggers quite a different set of problems with delayed psychological symptoms because of damage to property, social isolation and displacement of individuals. ^{Reference Bennett8-Reference Tunstall, Tapsell, Green, Floyd and George10}

The risk of individuals suffering from anxiety or depressive symptoms following an episode of flooding is greatly increased by pre-existing symptoms of depression, living alone and having limited social networks. ^{Reference Ginexi, Weihs, Simmens and Hoyt11} Reports have described delayed depressive and anxiety symptoms being triggered in response to later heavy rain or rising water levels. ^{Reference Messner12} Conversely, a study from Colorado, USA, has shown that the elderly who are psychologically healthy may be more resilient when confronted with flooding for a second or third time. This may be caused by an inoculation effect from previous experiences producing psychological resistance to fresh floods. ^{Reference Ferraro13}

Displacement has been well recognised as a trigger for psychological symptoms. ^{Reference Fullilove14} The longer someone has lived in a particular place as well as their age are risk factors for developing symptoms, most noticeably anxiety and depression, as a result of displacement. ^{Reference Phifer, Kaniasty and Norris7}

Following floods in Brisbane, Australia, there was evidence that elderly people may develop depression as a result of social isolation caused by flooding even though they are personally safe and have not suffered any damage to property. ^{Reference Price15} The loss of community spirit as a direct consequence of flooding has recognisable effects on the mental state of survivors. ¹⁶

Damage to property is frequently underappreciated by the public as a cause of distress. Instead, the media and the public focus on the threat to life and displacement of populations. Common foci of frustration following a flood are the loss of irreplaceable emotional items, the cost of repairs to someone's home, and the delay before homes become habitable again. The level of symptoms and the reported stress and anxiety correlate with the cost of the damage and the sense of loss. ¹⁶ Women have been found to be more affected by such material losses as they have greater emotional investment in the home and feel a greater responsibility to restore the household to normal. ^{Reference Tunstall9,Reference Tunstall, Tapsell, Green, Floyd and George10}

Although not observed among the problems confronting the CMHT, deterioration in physical health has been noted among elderly victims of flooding that is not explained by injury or infectious disease. ^{Reference Phifer, Kaniasty and Norris7} The Flood Hazard Research Centre survey reported that the experience of flooding as a traumatic event is more commonly observed in females and those in poor physical health. ^{Reference Tunstall9,Reference Tunstall, Tapsell, Green, Floyd and George10}

Rotherham Primary Care Trust stressed the importance of personal evacuation plans for residents of nursing homes. ¹⁷ This should include the provision of photographic identification that would accompany any person with cognitive impairment who, during a crisis, could have difficulty identifying themselves to new professionals.

Conclusions

Our brief report highlights that CMHTs should be alert to the impact of flooding on the elderly with mental illness and dementia - particularly in the days and weeks after the water levels have receded but the repairs to the flood damage are awaited. It is important to be on the lookout for undiagnosed dementia and exacerbations in depressive and anxiety disorders that may appear after several months. Our experience is consistent with previous reports that women are more likely to be negatively affected by the consequences of flooding.

The Environment Agency predicts that the risk of flooding has increased due to changes in weather patterns. It estimates that there are 1028 care homes in the UK that are at risk from flooding. ^{Reference Sayers, Panzeri, Ohl, Segura-Dominguez, Benwell and Deakin18} Special provision through personal evacuation plans should be made to correctly identify people with marked cognitive impairment when they need to be moved at very short notice. Overcrowding of care homes used to temporarily accommodate additional residents can contribute to behavioural difficulties and psychological symptoms in those with pre-existing dementia.

Finally, we must emphasise that we have only discussed here those factors that came to the attention of the CMHT - many elderly people suffer in silence or are managed solely by general practitioners.