Emergency department visits for behavioral and mental health care after a terrorist attack

Utilization of psychiatry services in the emergency department following a terror event in Israel

In October 2023, Israel sustained a massive terror attack, with 1,300 people murdered, over 240 kidnapped, and millions exposed to the horrors. This study's aim is to examine the profile of patients arriving to the emergency department (ED) for psychiatric services during the month following the attack, compared to a similar period the year prior. In this cohort study, we compared patients arriving to the ED of a large general hospital in the center of Tel Aviv for psychiatric services during the month post-attack with the previous year using t-tests and chi-square exams. In 2023, 256 patients arrived in the ED for psychiatric evaluation and/or treatment, 46 % more than in 2022. Of these, 64 % were examined due to symptoms related to the terror attack. In 2023, significantly fewer patients had a prior psychiatric diagnosis (68% vs. 89 %). Significantly more patients were diagnosed with acute stress reaction or acute stress disorder in the ED, compared to almost no such diagnoses in 2022 (14 % and 43% vs. 0 % and 1 %). Major terror incidents profoundly influence psychiatric ED visits. Planning efforts for major emergencies should be adapted accordingly.

The Impact of COVID-19 on Psychiatric Emergency and Inpatient Services in the First Month of the Pandemic in a Large Urban Mental Health Hospital in Ontario, Canada

The World Health Organization characterized COVID-19 (coronavirus disease 2019) as a pandemic on March 11, 2020 (WHO). Within a couple of days, all Canadian provinces announced the implementation of social distancing measures. We evaluated the immediate effect of COVID-19 on psychiatric emergency and inpatient services in Canada's largest psychiatric hospital in the first month of the pandemic. We extracted data from the electronic medical records of the Center for Addiction and Mental Health in Toronto, Canada. We compared emergency department visits, inpatient occupancy rates, and length of stay in March 2019 and March 2020, and during the first and second half of March 2020. There was a decrease in the number of emergency department visits and inpatient occupancy rates in March 2020 compared to March 2019. There was also a significant decrease in the number of emergency department visits and inpatient occupancy rates in the second half of March 2020 compared to the first half. Our findings suggest that the pandemic was followed by a rapid decrease in the usage of psychiatric emergency and inpatient services in a large mental health hospital. Future studies will need to assess whether this decrease will be followed by a return to baseline or an increase in need for these services.

Pediatric emergency department utilization during the COVID-19 pandemic in New York City

Objectives

This study describes the utilization of a pediatric emergency department (ED) during the early months of the COVID-19 pandemic in the initial U.S. epicenter, including the impact on visit acuity and incidences of common diagnoses.

Study Design

We performed an observational retrospective review of patients younger than 18 years old seen in a New York City pediatric ED from March 7th to May 6th 2020, and during the same time period in 2018 and 2019. Demographics, visit details, diagnoses, and dispositions were compared. Validated algorithms were utilized to create practical diagnosis groupings and to determine the probability of a visit requiring emergent evaluation.

Results

ED visits during the pandemic decreased by 56% to an average daily census of 67 patients, from an anticipated 152. Admission rates rose from 13.3% to 17.4% (p<0.001), and the proportion of triage Emergency Severity Index level 1 and 2 patients increased by 23.7% (p<0.001). Non-emergent visits dropped from 32.3% to 27.5% (p<0.001). Several common, often low-acuity diagnoses saw disproportionate reductions in visits including headache, chest pain, and minor injuries. Concerningly, visits for suicidal ideation, suicide attempt, or self-harm increased by 100% (p<0.001) and visits for evaluating abuse or neglect decreased by 89% (p=0.01).

Conclusions

Pediatric ED utilization substantially deceased during the early months of the COVID-19 pandemic in New York City, but left relatively higher patient acuity. Healthcare systems in early epicenters must also prepare for the disproportionate impact a pandemic has on the most vulnerable pediatric patients, particularly those at risk for self-harm or abuse.

Adjustment disorder with anxiety in old age: Comparing prevalence and clinical management in primary care and mental health care

Purpose:

Adjustment disorder with anxiety (AjD-A) is a common cause of severe anxiety symptoms, but little is known about its prevalence in old age.

Methods:

This cross-sectional study examined the prevalence of AjD-A in outpatients over the age of 60 who consecutively consulted 34 general practitioners and 22 psychiatrists during a 2-week period. The diagnosis of AjD-A was obtained using the optional module for diagnostic of adjustment disorder of the Mini International Neuropsychiatric Interview (MINI). The study procedure also explored comorbid psychiatric conditions and documented recent past stressful life events, as well as social disability and current pharmacological and non-pharmacological management.

Results:

Overall, 3651 consecutive subjects were screened (2937 in primary care and 714 in mental health care). The prevalence rate of AjD-A was 3.7% (n = 136). Up to 39% (n = 53) of AjD-A subjects had a comorbid psychiatric condition, mostly of the anxious type. The most frequently stressful life event reported to be associated with the onset of AjD-A was personal illness or health problem (29%). More than 50% of the AjD-A patients were markedly to extremely disabled by their symptoms. Compared to patients who consulted psychiatrists, patients who were seen by primary care physicians were older, had obtained lower scores at the Hamilton Anxiety Rating Scale, benefited less frequently from non-pharmacological management and received benzodiazepines more frequently.

Conclusions:

AjD-A appears to be a significantly disabling cause of anxiety symptoms in community dwelling elderly persons, in particular those presenting personal health related problems. Improvement of early diagnosis and non-pharmacological management of AjD-A would contribute to limit risks of benzodiazepine overuse, particularly in primary care settings.

Changes in Psychiatric Emergency Room Visits Following the Boston Marathon Bombing

OBJECTIVE

This study reviews patient encounters at a Boston-area community hospital Psychiatric Emergency Services (PES) following the Boston Marathon bombings, with the goal of describing the impact of terrorist attacks on PES encounters.

METHODS

All PES encounters for 2 months preceding and 2 months following the bombing were identified in the electronic medical record. Demographics, current and past psychiatric problems, and trauma history were assessed for all records. Encounters seen post-bombing were compared with those before the bombing.

RESULTS

Demographics, current and past psychiatric problems, and trauma history were not significantly different before versus after the bombing; 36 of 440 (8.2%) post-bombing encounters directly mentioned the bombings. New-onset posttraumatic stress disorder (PTSD) symptoms caused by the bombing occurred in only 4 encounters (0.9%).

CONCLUSIONS

PES encounters after a terrorist event are likely to mirror those seen before a terrorist event, with only a minority of encounters presenting for new PTSD or acute stress disorder.

The effect of a terrorist attack on emergency department inflow: an observation study using difference-in-differences methodology

Study objective

The objective of this study was to investigate how the terrorist attack in Stockholm, Sweden affected patient inflow to the general emergency departments (EDs) in close proximity of the attack. The study analyzed if, and to what extent, the attack impacted ED inflow during the following days and weeks.

Methods

In a retrospective observational study, anonymized aggregated data on ED arrivals (inflow of patients) to all seven of the EDs in the Stockholm County was analyzed using the Difference-in-Differences (DiD) estimator. The control groups were the affected hospitals in the years prior to the terrorist attack. The number of ED visits was retrieved from the Stockholm County Council administrative database.

Results

The study shows a statistically significant reduction in overall ED inflow of 7–9% following the attack. The effect was strongest initially after the attack, and ED inflow regained normal levels within approximately three weeks’ time, without any significant rebound effect. The effect on ED inflow also decreased with distance from ground zero, and was not significant further away than 10 km.

Conclusion

The results showed that ED inflow was significantly decreased in the weeks immediately following the Stockholm terrorist attack. The reasons for this cannot be fully explained in this observational study. However, the results suggest that some patients actively choose when, where and if they should go to the ED.

Neurological disease in the aftermath of terrorism: a review

The purpose of our review is to discuss current knowledge on long-term sequelae and neurological disorders in the aftermath of a terrorist attack. The specific aspects of both psychological and physical effects are mentioned in more detail in this review. Also, the outcomes such as stress-related disorders, cardiovascular disease, and neurodegenerative disease are explained. Moreover, PTSD and posttraumatic structural brain changes are a topic for further investigations of the patients suffering from these attacks. Not only the direct victims are prone to the after effects of the terroristic attacks, but the rescue workers, physicians, witnesses and worldwide citizens may also be affected by PTSD and other neurological diseases as well. The determination of a whole series of risk factors for developing neurological disorders can be a means to set up early detection, preventative measures, to refine treatment and thus to gain better outcome in the future.

Cross-sectional survey on self-reported health of ambulance personnel

Background

The high job stress among ambulance personnel is a widely known phenomenon. Purpose: to asses the self reported health status of ambulance workers.

Methods

An anonym self-fill-in questionnaire applying SF-36 was used among workers from the northern and western regions of Hungarian National Ambulance Service.

Results

Based on the dimensions of the SF-36 questionnaire the respondents considered their “Physical Functioning” the best, while “Vitality” was regarded the worst. The more time an employee have been worked at the HNAS the worse his health was in the first four dimensions like, “Physical Functioning”, “Role-Physical”, “Bodily Pain”, “General Health”: p < 0.001. Those working in secondary part-time jobs considered their health in all dimensions worse. The respondents who did some kind of sports hold their health in all dimensions better (p < 0.001). The workers with higher BMI regarded their health status worse, in four dimensions: “Physical Functioning”: p = 0.001; “Role-Physical”: p = 0.013; “General Health”: p < 0.001; “Role-Emotional”: p = 0.05.

Conclusions

The workers health status proved to be insufficient according to the subjective perception and measurable parameters. According to the subjective perception of health and measurable parameters of health status of workers proved to be insufficient. Poor physical health can lead indirectly to psychological problems, which may lower the quality of the work and can lead to high turn-over.

Emergency Mental Health Services for Children After the Terrorist Attacks of September 11, 2001

Much literature documents elevated psychiatric symptoms among adults after the terrorist attacks of September 11, 2001 (9/11). We, however, know of no research in children that examines emergency mental health services following 9/11. We test whether children's emergency services for crisis mental health care rose above expected values in September 2001. We applied time-series methods to California Medicaid claims (1999-2003; N = 127,200 visits). Findings in California indicate an 8.7% increase of children's emergency mental health visits statistically attributable to 9/11. Non-Hispanic white more than African American children account for this acute rise in emergency services.

School interventions after the Joplin tornado

BACKGROUND/OBJECTIVE

To qualitatively describe interventions by schools to meet children's needs after the May 2011 Joplin, Missouri tornado.

METHODS

Qualitative exploratory study conducted six months after the tornado. Key informant interviews with school staff (teachers, psychologists, guidance counselor, nurse, principal), public health official, and physicians.

REPORT

After the tornado, school staff immediately worked to contact every enrolled child to provide assistance and coordinate recovery services. Despite severe damage to half of the city's schools, the decision was made to reopen schools at the earliest possible time to provide a safe, reassuring environment and additional services. An expanded summer school session emphasized child safety and emotional wellbeing. The 2011-2012 school year began on time, less than three months after the disaster, using temporary facilities. Displaced children were bused to their usual schools regardless of their new temporary residence locations. In just-in-time training sessions, teachers developed strategies to support students and staff experiencing anxiety or depression. Certified counselors conducted school-based, small-group counseling for students. Selective referrals were made to community mental health providers for children with greatest needs.

CONCLUSIONS

Evidence from Joplin adds to a small body of empirical experience demonstrating the important contribution of schools to postdisaster community recovery. Despite timely and proactive services, many families and children struggled after the tornado. Improvements in the effectiveness of postdisaster interventions at schools will follow from future scientific evidence on optimal approaches.

The enduring mental health impact of the September 11th terrorist attacks: challenges and lessons learned

The authors review the existing literature on the mental health impact of the September 11th attacks and the implications for disaster mental health clinicians and policy makers. The authors discuss the demographic characteristics of those affected and the state of mental health needs and existing mental health delivery services; the nature of the disaster and primary impacts on lives, infrastructure, and socioeconomic factors; the acute aftermath in the days and weeks after the attacks; the persistent mental health impact and evolution of services of the postacute aftermath; and the implications for future disaster mental health practitioners and policy makers.

Analyzing Postdisaster Surveillance Data: The Effect of the Statistical Method

Data from existing administrative databases and ongoing surveys or surveillance methods may prove indispensable after mass traumas as a way of providing information that may be useful to emergency planners and practitioners. The analytic approach, however, may affect exposure prevalence estimates and measures of association. We compare Bayesian hierarchical modeling methods to standard survey analytic techniques for survey data collected in the aftermath of a terrorist attack. Estimates for the prevalence of exposure to the terrorist attacks of September 11, 2001, varied by the method chosen. Bayesian hierarchical modeling returned the lowest estimate for exposure prevalence with a credible interval spanning nearly 3 times the range of the confidence intervals (CIs) associated with both unadjusted and survey procedures. Bayesian hierarchical modeling also returned a smaller point estimate for measures of association, although in this instance the credible interval was tighter than that obtained through survey procedures. Bayesian approaches allow a consideration of preexisting assumptions about survey data, and may offer potential advantages, particularly in the uncertain environment of postterrorism and disaster settings. Additional comparative analyses of existing data are necessary to guide our ability to use these techniques in future incidents. (Disaster Med Public Health Preparedness. 2008;2:119–126)

Prioritizing "psychological" consequences for disaster preparedness and response: a framework for addressing the emotional, behavioral, and cognitive effects of patient surge in large-scale disasters

While information for the medical aspects of disaster surge is increasingly available, there is little guidance for health care facilities on how to manage the psychological aspects of large-scale disasters that might involve a surge of psychological casualties. In addition, no models are available to guide the development of training curricula to address these needs. This article describes 2 conceptual frameworks to guide hospitals and clinics in managing such consequences. One framework was developed to understand the antecedents of psychological effects or "psychological triggers" (restricted movement, limited resources, limited information, trauma exposure, and perceived personal or family risk) that cause the emotional, behavioral, and cognitive reactions following large-scale disasters. Another framework, adapted from the Donabedian quality of care model, was developed to guide appropriate disaster response by health care facilities in addressing the consequences of reactions to psychological triggers. This framework specifies structural components (internal organizational structure and chain of command, resources and infrastructure, and knowledge and skills) that should be in place before an event to minimize consequences. The framework also specifies process components (coordination with external organizations, risk assessment and monitoring, psychological support, and communication and information sharing) to support evidence-informed interventions.

Discrimination and racial disparities in health: evidence and needed research

This paper provides a review and critique of empirical research on perceived discrimination and health. The patterns of racial disparities in health suggest that there are multiple ways by which racism can affect health. Perceived discrimination is one such pathway and the paper reviews the published research on discrimination and health that appeared in PubMed between 2005 and 2007. This recent research continues to document an inverse association between discrimination and health. This pattern is now evident in a wider range of contexts and for a broader array of outcomes. Advancing our understanding of the relationship between perceived discrimination and health will require more attention to situating discrimination within the context of other health-relevant aspects of racism, measuring it comprehensively and accurately, assessing its stressful dimensions, and identifying the mechanisms that link discrimination to health.

Discrimination and racial disparities in health: evidence and needed research

This paper provides a review and critique of empirical research on perceived discrimination and health. The patterns of racial disparities in health suggest that there are multiple ways by which racism can affect health. Perceived discrimination is one such pathway and the paper reviews the published research on discrimination and health that appeared in PubMed between 2005 and 2007. This recent research continues to document an inverse association between discrimination and health. This pattern is now evident in a wider range of contexts and for a broader array of outcomes. Advancing our understanding of the relationship between perceived discrimination and health will require more attention to situating discrimination within the context of other health-relevant aspects of racism, measuring it comprehensively and accurately, assessing its stressful dimensions, and identifying the mechanisms that link discrimination to health.

Bayesian hierarchical spatial modeling of substance abuse patterns following a mass trauma: the role of time and place

To illustrate how spatial modeling methods may provide insight about the relation between proximity to mass trauma and substance use, we examined the role of proximity to a terrorist event in determining risk of substance use related diagnoses. Previous analyses that have assessed changes in substance use following mass traumas such as terrorist attacks have produced conflicting results. We used Bayesian hierarchical modeling methods to assess whether distance from the World Trade Center (WTC) site in the aftermath of the September 11, 2001 terrorist attacks was associated with risk of substance use related diagnoses. In analyses controlling for age, gender, median household income, and employment-related exposure to the terrorist attacks, we found that each two mile increment in distance away from the WTC site was associated with 18% more substance use related diagnoses in the population we studied; this relation between distance from the WTC and substance use related disorder was the opposite of the relations observed one year before the same attacks in the same area. By accounting for spatial relationships that may influence the population risk of substance use health disorder, this approach helps explain some of the conflicting observations in the extant literature. These methods hold promise for the characterization of disease risk where spatial patterning of exposures and outcomes may matter.

Discrimination and racial disparities in health: evidence and needed research

This paper provides a review and critique of empirical research on perceived discrimination and health. The patterns of racial disparities in health suggest that there are multiple ways by which racism can affect health. Perceived discrimination is one such pathway and the paper reviews the published research on discrimination and health that appeared in PubMed between 2005 and 2007. This recent research continues to document an inverse association between discrimination and health. This pattern is now evident in a wider range of contexts and for a broader array of outcomes. Advancing our understanding of the relationship between perceived discrimination and health will require more attention to situating discrimination within the context of other health-relevant aspects of racism, measuring it comprehensively and accurately, assessing its stressful dimensions, and identifying the mechanisms that link discrimination to health.